"Providing first aid for various conditions"

Emergency conditions that threaten the life and health of the patient require urgent measures at all stages of medical care. These conditions arise due to the development of shock, acute blood loss, respiratory distress, circulatory disorders, coma, which are caused by acute diseases internal organs, traumatic injuries, poisonings and accidents.

The most important place in providing assistance to those suddenly ill and injured as a result of natural and man-made emergencies in peacetime is to carry out adequate pre-hospital measures. According to data from domestic and foreign specialists, a significant number of patients and victims of emergencies could have been saved if timely and effective delivery assistance at the prehospital stage.

Currently, the importance of first aid in the treatment of emergency conditions has increased enormously. The ability of nursing staff to assess the severity of the patient’s condition and identify priority problems is necessary to provide effective pre-medical care, which can greatly influence the further course and prognosis of the disease. A medical professional is required not only to have knowledge, but also to be able to quickly provide assistance, since confusion and inability to collect oneself can even aggravate the situation.

Thus, mastering the techniques of providing emergency medical care at the prehospital stage to sick and injured people, as well as improving practical skills, is an important and urgent task.

Modern principles of emergency medical care

In world practice, a universal scheme for providing assistance to victims at the prehospital stage has been adopted.

The main stages of this scheme are:

1. Immediate initiation of emergency life-sustaining measures in the event of emergency conditions.

2. Organizing the arrival of qualified specialists at the scene of the incident as soon as possible, performing certain emergency medical care measures during transport of the patient to the hospital.

The fastest possible hospitalization to a specialized medical institution that has qualified medical personnel and is equipped with the necessary equipment.

Measures to be taken in case of emergency conditions

Medical and evacuation measures carried out during the provision of emergency care, should be divided into a number of interrelated stages - pre-hospital, hospital and first medical aid.

At the prehospital stage, first, pre-medical and first medical aid is provided.

The most important factor when providing emergency care is the time factor. The best treatment results for victims and patients are achieved when the period from the onset of an emergency to the time of provision of qualified assistance does not exceed 1 hour.

A preliminary assessment of the severity of the patient’s condition will help to avoid panic and fuss during subsequent actions, will make it possible to make more balanced and rational decisions in extreme situations, as well as measures for emergency evacuation of the victim from the danger zone.

After this, it is necessary to begin identifying the signs of the most life-threatening conditions that can lead to the death of the victim in the coming minutes:

· clinical death;

· comatose state;

· arterial bleeding;

· neck wounds;

· Chest injuries.

Those providing assistance to victims in an emergency must strictly adhere to the algorithm shown in Diagram 1.

Scheme 1. Procedure for providing assistance in case of emergency

Providing first aid in case of emergency

There are 4 basic principles of first aid that should be followed:

Inspection of the scene of the incident. Ensure safety when providing assistance.

2. Initial examination of the victim and provision of first aid for life-threatening conditions.

Call a doctor or ambulance.

Secondary examination of the victim and, if necessary, assistance in identifying other injuries and illnesses.

Before providing assistance to victims, find out:

· Is the scene of the incident dangerous?

· What happened;

· Number of patients and injured;

· Are others able to help?

Of particular importance is anything that could threaten your safety and the safety of others: exposed electrical wires, falling debris, intense traffic, fire, smoke, harmful fumes. If you are in any danger, do not approach the victim. Immediately call the appropriate rescue service or police for professional assistance.

Always look for other victims and, if necessary, ask others to assist you in providing assistance.

As soon as you approach the conscious victim, try to calm him down, then in a friendly tone:

· find out from the victim what happened;

· explain that you are a medical professional;

· offer assistance, obtain the victim’s consent to provide assistance;

· Explain what action you are going to take.

Before you begin providing emergency medical care, you should obtain the victim's permission to do so. A conscious victim has the right to refuse your service. If he is unconscious, we can assume that you have obtained his consent to carry out emergency measures.

Bleeding

Methods to stop bleeding:

1. Finger pressure.

2. Tight bandage.

Maximum limb flexion.

Application of a tourniquet.

Applying a clamp to a damaged vessel in a wound.

Wound tamponade.

If possible, use a sterile dressing (or clean cloth) to apply a pressure bandage, apply it directly to the wound (to avoid eye injury and depression of the skull vault).

Any movement of the limb stimulates blood flow in it. In addition, when blood vessels are damaged, blood clotting processes are disrupted. Any movements cause additional damage to blood vessels. Splinting the limbs can reduce bleeding. In this case, air tires, or any type of tire, are ideal.

When applying a pressure bandage to a wound site does not reliably stop bleeding or there are multiple sources of bleeding supplied by a single artery, local compression may be effective.

If there is bleeding in the scalp area, the temporal artery should be pressed against the surface of the temporal bone. Brachial artery - to the surface humerus with forearm injury. Femoral artery- to the pelvic or femoral bone in case of injury to the lower limb.

It is necessary to apply a tourniquet only in extreme cases, when all other measures have not given the expected result.

Principles of applying a tourniquet:

§ I apply a tourniquet above the bleeding site and as close to it as possible over clothing or over several rounds of bandage;

§ the tourniquet should be tightened only until the peripheral pulse disappears and bleeding stops;

§ each subsequent tour of the bundle must partially cover the previous tour;

§ the tourniquet is applied for no more than 1 hour during a warm period, and no more than 0.5 hour during a cold period;

§ a note is inserted under the applied tourniquet indicating the time of application of the tourniquet;

§ after the bleeding has stopped, a sterile bandage is applied to the open wound, bandaged, the limb is fixed and the wounded person is sent to the next stage of medical care, i.e. evacuated.

A tourniquet can damage nerves and blood vessels and even lead to the loss of a limb. A loose tourniquet can stimulate more intense bleeding, since not arterial, but only venous blood flow stops. Use a tourniquet as a last resort for life-threatening conditions.

Fractures

§ passability check respiratory tract, breathing and circulation;

§ imposition of transport immobilization with service means;

§ aseptic dressing;

§ anti-shock measures;

§ transportation to health care facilities.

For a fracture of the lower jaw:

Urgent first aid:

§ check airway patency, breathing, blood circulation;

§ arterial bleeding temporarily stop by applying pressure to the bleeding vessel;

§ secure the lower jaw with a sling-shaped bandage;

§ If your tongue retracts, making breathing difficult, fix your tongue.

Rib fractures.

Emergency first aid:

§ As you exhale, apply a circular pressure bandage to the chest;

§ With injuries to the chest organs, call an ambulance to hospitalize the victim in a hospital specializing in chest injuries.

Wounds

Emergency first aid:

§ check ABC (airway patency, breathing, circulation);

§ During the primary care period, simply rinse the wound with saline or clean water and apply a clean bandage, elevate the limb.

Emergency first aid for open wounds:

§ stop the main bleeding;

§ remove dirt, splinters and debris by irrigating the wound with clean water, saline solution;

§ apply an aseptic bandage;

§ for extensive wounds, immobilize the limb

Lacerations are divided into:

superficial (including only the skin);

deep (involve underlying tissues and structures).

Puncture wounds usually not accompanied by massive external bleeding, but be alert to the possibility of internal bleeding or tissue damage.

Emergency first aid:

§ do not remove deeply stuck objects;

§ stop the bleeding;

§ Stabilize the foreign body with a bulky dressing and immobilize with splints as necessary.

§ Apply an aseptic bandage.

Thermal lesions

Burns

Emergency first aid:

§ termination of the thermal factor;

§ cooling the burned surface with water for 10 minutes;

§ applying an aseptic dressing to the burn surface;

§ warm drink;

§ evacuation to the nearest health facility in a prone position.

Frostbite

Emergency first aid:

§ stop the cooling effect;

§ after removing damp clothing, cover the victim warmly and give him a hot drink;

§ provide thermal insulation of cooled limb segments;

§ evacuate the victim to the nearest health care facility in a prone position.

Sun and heat stroke

Emergency first aid:

§ Move the victim to a cooler place and give him a moderate amount of liquid to drink;

§ put cold on the head, on the heart area;

§ Lay the victim on his back;

§ If the victim’s blood pressure has dropped, raise the lower limbs.

Acute vascular insufficiency

Fainting

Emergency first aid:

§ Lay the patient on his back with his head slightly lowered or raise the patient’s legs to a height of 60-70 cm in relation to the horizontal surface;

§ loosen tight clothing;

§ provide access to fresh air;

§ bring a cotton swab moistened with ammonia to your nose;

§ Spray your face cold water or pat his cheeks, rub his chest;

§ Make sure that the patient sits for 5-10 minutes after fainting;

If an organic cause of syncope is suspected, hospitalization is necessary.

Convulsions

Emergency first aid:

§ protect the patient from bruises;

§ free him from restrictive clothing;

emergency health care

§ free the patient’s oral cavity from foreign objects (food, removable dentures);

§ To prevent tongue bite, insert the corner of a rolled towel between your molars.

Strike by lightning

Emergency first aid:

§ restoration and maintenance of airway patency and artificial ventilation of the lungs;

§ indirect cardiac massage;

§ hospitalization, transporting the victim on a stretcher (preferably in a side position due to the risk of vomiting).

Pelectric shock

First aid for electrical injury:

§ release the victim from contact with the electrode;

§ preparing the victim for resuscitation measures;

§ performing mechanical ventilation in parallel with closed cardiac massage.

Bee, wasp, bumblebee stings

Emergency first aid:

· remove the sting from the wound with tweezers;

· treat the wound with alcohol;

· Apply a cold compress.

Hospitalization is necessary only for general or severe local reactions.

Poisonous snake bites

Emergency first aid:

§ complete rest in horizontal position;

§ local - cold;

§ immobilization of the injured limb using improvised means;

§ drinking plenty of water;

§ transportation in a lying position;

Sucking blood from a wound with your mouth is prohibited!

Bites from dogs, cats, wild animals

Emergency first aid:

§ when bitten pet dog and the presence of a small wound, toilet the wound;

§ a bandage is applied;

§ the victim is sent to a trauma center;

§ large bleeding wounds are packed with napkins.

Indications for hospitalization are bite wounds received from unknown animals that have not been vaccinated against rabies.

Poisoning

Emergency first aid for acute oral poisoning:

· perform gastric lavage naturally (induce vomiting);

· provide oxygen access;

· ensure prompt transportation to a specialized toxicology department.

Emergency first aid for inhalation poisoning:

· stop the flow of poison into the body;

Provide the victim with oxygen;

· ensure prompt transportation to a specialized toxicology department or intensive care unit.

Emergency first aid for resorptive poisoning:

· stop the flow of poison into the body;

· clean and wash the skin from the toxic substance (use a soap solution for washing)

· If necessary, provide transportation to a health facility.

Poisoning with alcohol and its substitutes

Emergency first aid:

· drinking plenty of water;

Acetic acid

Emergency first aid:

· while maintaining consciousness, give 2-3 glasses of milk orally, 2 raw eggs;

· ensure the patient is transported to the nearest health facility in a lateral decubitus position.

Carbon monoxide

Emergency first aid: drag the victim to a safe place; unfasten the belt, collar, provide access to fresh air; warm the victim; ensure hospitalization of the victim in a medical facility.

Mushroom poisoning

Emergency first aid:

· tubeless gastric lavage;

· drinking plenty of water;

· inside adsorbents - activated carbon and laxative;

· ensure the patient is transported to the nearest health facility in a lateral decubitus position.

Personal safety and protective measures for medical personnel when providing emergency care

Prevention of occupational infection includes universal precautionary measures, which involve the implementation of a number of measures aimed at preventing contact of medical workers with biological fluids, organs and tissues of patients, regardless of epidemiological history, the presence or absence of specific diagnostic results.

Medical workers must treat blood and other biological fluids of the human body as potentially dangerous in terms of possible infection, therefore, when working with them, the following rules must be observed:

In case of any contact with blood, other biological fluids, organs and tissues, as well as with mucous membranes or damaged skin of patients, a medical worker must be dressed in special clothing.

2. Other means of barrier protection - a mask and goggles - should be worn in cases where the possibility of splashing blood and other biological fluids cannot be excluded.

When performing various procedures, it is necessary to take measures to prevent injury from cutting and piercing objects. Cutting and piercing instruments must be handled carefully, without unnecessary fussiness, and every movement must be made thoughtfully.

If an “emergency situation” occurs, it is necessary to use the device for emergency prevention of parenteral viral hepatitis and HIV infection.

First aid is a set of urgent measures aimed at saving a person’s life. An accident, a sudden attack of illness, poisoning - in these and other emergency situations, competent first aid is necessary.

According to the law, first aid is not medical - it is provided before the arrival of doctors or the delivery of the victim to the hospital. First aid can be provided by anyone who is near the victim at a critical moment. For some categories of citizens, providing first aid is an official duty. We are talking about police officers, traffic police and the Ministry of Emergency Situations, military personnel, and firefighters.

The ability to provide first aid is a basic but very important skill. It can save someone's life. Here are 10 basic first aid skills.

First aid algorithm

In order not to get confused and provide first aid correctly, it is important to follow the following sequence of actions:

1. Make sure that when providing first aid you are not in danger and you are not putting yourself in danger.
2. Ensure the safety of the victim and others (for example, remove the victim from a burning car).
3. Check the victim for signs of life (pulse, breathing, reaction of pupils to light) and consciousness. To check breathing, you need to tilt the victim's head back, lean towards his mouth and nose and try to hear or feel breathing. To detect the pulse, you need to place your fingertips on the victim’s carotid artery. To assess consciousness, it is necessary (if possible) to take the victim by the shoulders, gently shake him and ask a question.
4. Call specialists: from the city - 03 (ambulance) or 01 (rescue).
5. Provide emergency first aid. Depending on the situation, this could be:
   • restoration of airway patency;
   • cardiopulmonary resuscitation;
   • stopping bleeding and other measures.
6. Provide the victim with physical and psychological comfort and wait for specialists to arrive.

Artificial respiration

Artificial pulmonary ventilation (ALV) is the introduction of air (or oxygen) into a person’s respiratory tract in order to restore natural ventilation of the lungs. Refers to basic resuscitation measures.

Typical situations requiring mechanical ventilation:

• car accident;
• accident on the water;
• electric shock and others.

There are various methods of mechanical ventilation. The most effective means of providing first aid to a non-specialist are mouth-to-mouth and mouth-to-nose artificial respiration.

If, upon examination of the victim, natural breathing is not detected, artificial ventilation of the lungs must be performed immediately.

Mouth-to-mouth artificial respiration technique

1. Ensure patency of the upper respiratory tract. Turn the victim's head to the side and use your finger to remove mucus, blood, and foreign objects from the mouth. Check the victim's nasal passages and clear them if necessary.
2. Tilt the victim's head back, holding the neck with one hand.
   

   Do not change the position of the victim’s head if there is a spinal injury!

3. Place a napkin, handkerchief, piece of cloth or gauze over the victim's mouth to protect yourself from infections. Pinch the victim's nose with your thumb and index finger. Take a deep breath and press your lips firmly against the victim's mouth. Exhale into the victim's lungs.
   

   The first 5–10 exhalations should be quick (in 20–30 seconds), then 12–15 exhalations per minute.

4. Observe the movement of the victim's chest. If the victim’s chest rises when he inhales air, then you are doing everything right.

Indirect cardiac massage

If there is no pulse along with breathing, it is necessary to perform an indirect cardiac massage.

Indirect (closed) cardiac massage, or chest compression, is the compression of the heart muscles between the sternum and the spine in order to maintain a person’s blood circulation during cardiac arrest. Refers to basic resuscitation measures.

Attention! Cannot be carried out indoor massage heart in the presence of a pulse.

Indirect cardiac massage technique

1. Place the victim on a flat, hard surface. Chest compressions should not be performed on beds or other soft surfaces.
2. Determine the location of the affected xiphoid process. The xiphoid process is the shortest and narrowest part of the sternum, its end.
3. Measure 2–4 cm up from the xiphoid process - this is the point of compression.
4. Place the heel of your palm on the compression point. Wherein thumb should point to either the chin or abdomen of the victim, depending on the location of the resuscitator. Place your other palm on top of one hand, clasping your fingers. Pressure is applied strictly with the base of the palm - your fingers should not touch the victim’s sternum.
5. Perform rhythmic chest thrusts strongly, smoothly, strictly vertically, using the weight of the upper half of your body. Frequency - 100–110 pressures per minute. In this case, the chest should bend by 3–4 cm.
   

   For infants, indirect cardiac massage is performed with the index and middle finger of one hand. For teenagers - with the palm of one hand.

If mechanical ventilation is performed simultaneously with closed cardiac massage, every two breaths should alternate with 30 compressions on the chest.

If during resuscitation measures the victim regains breathing or has a pulse, stop providing first aid and place the person on his side with his palm under his head. Monitor his condition until paramedics arrive.

Heimlich maneuver

When food or foreign bodies enter the trachea, it becomes blocked (fully or partially) - the person suffocates.

Signs of a blocked airway:

• Lack of full breathing. If the windpipe is not completely blocked, the person coughs; if completely, he holds on to the throat.
• Inability to speak.
• Blue discoloration of facial skin, swelling of neck vessels.

Airway clearance is most often carried out using the Heimlich method.

1. Stand behind the victim.
2. Grasp it with your hands, clasping them together, just above the navel, under the costal arch.
3. Press firmly on the victim's abdomen while sharply bending your elbows.
   

   Do not squeeze the victim's chest, with the exception of pregnant women, for whom pressure is applied to the lower chest.

4. Repeat the dose several times until the airways are clear.

If the victim has lost consciousness and fallen, place him on his back, sit on his hips and press on the costal arches with both hands.

To remove foreign bodies from the child’s respiratory tract, you need to turn him on his stomach and pat him 2-3 times between the shoulder blades. Be very careful. Even if your baby coughs quickly, consult a doctor for a medical examination.

Bleeding

Control of bleeding is measures aimed at stopping blood loss. When providing first aid, we are talking about stopping external bleeding. Depending on the type of vessel, capillary, venous and arterial bleeding are distinguished.

Stopping capillary bleeding is carried out by applying an aseptic bandage, and also, if the arms or legs are injured, by raising the limbs above the level of the body.

At venous bleeding a pressure bandage is applied. To do this, wound tamponade is performed: gauze is applied to the wound, several layers of cotton wool are placed on top of it (if there is no cotton wool, a clean towel), and bandaged tightly. The veins compressed by such a bandage quickly thrombose, and the bleeding stops. If the pressure bandage gets wet, apply firm pressure with the palm of your hand.

To stop arterial bleeding, the artery must be clamped.

Artery clamping technique: Press the artery firmly with your fingers or fist against the underlying bone formation.

The arteries are easily accessible for palpation, so this method is very effective. However, it requires physical strength from the first aider.

If the bleeding does not stop after applying a tight bandage and pressing the artery, use a tourniquet. Remember that this is a last resort when other methods fail.

Technique for applying a hemostatic tourniquet

1. Apply a tourniquet to clothing or soft padding just above the wound.
2. Tighten the tourniquet and check the pulsation of the blood vessels: the bleeding should stop and the skin below the tourniquet should turn pale.
3. Apply a bandage to the wound.
4. Record the exact time the tourniquet is applied.

The tourniquet can be applied to the limbs for a maximum of 1 hour. After it expires, the tourniquet must be loosened for 10–15 minutes. If necessary, you can tighten it again, but no more than 20 minutes.

Fractures

A fracture is a violation of the integrity of a bone. The fracture is accompanied severe pain, sometimes - fainting or shock, bleeding. There are open and closed fractures. The first is accompanied by injury to soft tissues; bone fragments are sometimes visible in the wound.

First aid technique for fracture

1. Assess the severity of the victim’s condition and determine the location of the fracture.
2. If there is bleeding, stop it.
3. Determine whether the victim can be moved before specialists arrive.
   

   Do not carry the victim or change his position if there is a spinal injury!

4. Ensure the bone immobility in the fracture area - perform immobilization. To do this, it is necessary to immobilize the joints located above and below the fracture.
5. Apply a splint. You can use flat sticks, boards, rulers, rods, etc. as a tire. The splint must be secured tightly, but not tightly, with bandages or plaster.

With a closed fracture, immobilization is performed over clothing. In case of an open fracture, do not apply a splint to places where the bone protrudes outward.

Burns

A burn is damage to body tissues caused by high temperatures or chemicals. Burns vary in severity as well as types of damage. According to the latter basis, burns are distinguished:

• thermal (flame, hot liquid, steam, hot objects);
• chemical (alkalis, acids);
• electrical;
• radiation (light and ionizing radiation);
• combined.

In case of burns, the first step is to eliminate the effect of the damaging factor (fire, electric current, boiling water, and so on).

Then, in case of thermal burns, the affected area should be freed from clothing (carefully, without tearing it off, but cutting off the adhering tissue around the wound) and, for the purpose of disinfection and pain relief, irrigate it with a water-alcohol solution (1/1) or vodka.

Do not use oil-based ointments and fatty creams - fats and oils do not reduce pain, do not disinfect the burn, or promote healing.

Afterwards, irrigate the wound with cold water, apply a sterile bandage and apply cold. Also, give the victim warm, salted water.

To speed up the healing of minor burns, use sprays with dexpanthenol. If the burn covers an area larger than one palm, be sure to consult a doctor.

Fainting

Fainting is sudden loss consciousness caused by a temporary disruption of cerebral blood flow. In other words, this is a signal from the brain that it does not have enough oxygen.

It is important to distinguish between normal and epileptic syncope. The first is usually preceded by nausea and dizziness.

A pre-fainting state is characterized by the fact that a person rolls his eyes, breaks out in a cold sweat, his pulse weakens, and his limbs become cold.

Typical situations of fainting:

• fright,
• excitement,
• stuffiness and others.

If a person faints, give him a comfortable horizontal position and provide fresh air (unfasten clothes, loosen belt, open windows and doors). Spray the victim's face with cold water and pat his cheeks. If you have a first aid kit on hand, give a cotton swab soaked in ammonia a sniff.

If consciousness does not return within 3–5 minutes, call an ambulance immediately.

When the victim comes to his senses, give him strong tea or coffee.

Drowning and sunstroke

Drowning is the penetration of water into the lungs and airways, which can lead to death.

First aid for drowning

1. Remove the victim from the water.
   

   A drowning man grabs whatever he can get his hands on. Be careful: swim up to him from behind, hold him by the hair or armpits, keeping your face above the surface of the water.

2. Place the victim with his stomach on his knee so that his head is down.
3. Clear oral cavity from foreign bodies (mucus, vomit, algae).
4. Check for signs of life.
5. If there is no pulse or breathing, immediately begin mechanical ventilation and chest compressions.
6. Once breathing and cardiac function have been restored, place the victim on his side, cover him and keep him comfortable until paramedics arrive.

In summer, sunstroke is also a danger. Sunstroke is a brain disorder caused by prolonged exposure to the sun.

Symptoms:

• headache,
• weakness,
• noise in ears,
• nausea,
• vomit.

If the victim continues to remain in the sun, his temperature rises, shortness of breath appears, and sometimes he even loses consciousness.

Therefore, when providing first aid, it is first necessary to move the victim to a cool, ventilated place. Then free him from his clothes, loosen the belt, and take him off. Place a cold, wet towel on his head and neck. Give it a sniff of ammonia. Give artificial respiration if necessary.

In case of sunstroke, the victim must be given plenty of cool, slightly salted water to drink (drink often, but in small sips).

The causes of frostbite are high humidity, frost, wind, and immobile position. Alcohol intoxication usually aggravates the victim's condition.

Symptoms:

• feeling cold;
• tingling in the frostbitten part of the body;
• then - numbness and loss of sensitivity.

First aid for frostbite

1. Keep the victim warm.
2. Remove frozen or wet clothing.
3. Do not rub the victim with snow or cloth - this will only injure the skin.
4. Wrap up the frostbitten area of ​​your body.
5. Give the victim a hot sweet drink or hot food.

Poisoning

Poisoning is a disorder of the body's functioning that occurs due to the ingestion of a poison or toxin. Depending on the type of toxin, poisoning is distinguished:

• carbon monoxide,
• pesticides,
• alcohol,
• medications,
• food and others.

First aid measures depend on the nature of the poisoning. Most common food poisoning accompanied by nausea, vomiting, diarrhea and stomach pain. In this case, the victim is recommended to take 3-5 grams of activated carbon every 15 minutes for an hour, drink plenty of water, refrain from eating and be sure to consult a doctor.

In addition, accidental or intentional drug poisoning, as well as alcohol intoxication, are common.

In these cases, first aid consists of the following steps:

1. Rinse the victim's stomach. To do this, make him drink several glasses of salted water (for 1 liter - 10 g of salt and 5 g of soda). After 2–3 glasses, induce vomiting in the victim. Repeat these steps until the vomit is clear.
   

   Gastric lavage is only possible if the victim is conscious.

2. Dissolve 10–20 tablets of activated carbon in a glass of water and give it to the victim to drink.
3. Wait for the specialists to arrive.

Clinical manifestations

First aid

In case of a neurovegetative form of crisis Sequence of actions:

1) administer 4–6 ml of 1% furosemide solution intravenously;

2) administer 6–8 ml of 0.5% dibazole solution dissolved in 10–20 ml of 5% glucose solution or 0.9% sodium chloride solution intravenously;

3) administer 1 ml of 0.01% solution of clonidine in the same dilution intravenously;

4) administer 1–2 ml of a 0.25% solution of droperidol in the same dilution intravenously.

In the water-salt (edematous) form of crisis:

1) administer 2–6 ml of 1% furosemide solution intravenously once;

2) administer 10–20 ml of 25% magnesium sulfate solution intravenously.

In a convulsive form of crisis:

1) administer intravenously 2–6 ml of a 0.5% solution of diazepam, diluted in 10 ml of a 5% glucose solution or 0.9% sodium chloride solution;

2) antihypertensive drugs and diuretics - according to indications.

In case of a crisis associated with sudden withdrawal (cessation of taking) antihypertensive drugs: administer 1 ml of 0.01% solution of clonidine diluted in 10–20 ml of 5% glucose solution or 0.9% sodium chloride solution.

Notes

1. Drugs should be administered sequentially, under blood pressure control;

2. In the absence of a hypotensive effect within 20–30 minutes, the presence of acute cerebrovascular accident, cardiac asthma, or angina pectoris requires hospitalization in a multidisciplinary hospital.

Angina pectoris

Clinical manifestations s–m. Nursing in therapy.

First aid

1) stop physical activity;

2) sit the patient with support on his back and with his legs down;

3) give him a nitroglycerin or validol tablet under his tongue. If heart pain does not stop, repeat taking nitroglycerin every 5 minutes (2-3 times). If there is no improvement, call a doctor. Before he arrives, move on to the next stage;

4) in the absence of nitroglycerin, you can give the patient 1 tablet of nifedipine (10 mg) or molsidomine (2 mg) under the tongue;

5) give an aspirin tablet (325 or 500 mg) to drink;

6) invite the patient to drink hot water in small sips or place a mustard plaster on the heart area;

7) if there is no effect of therapy, hospitalization of the patient is indicated.

Myocardial infarction

Clinical manifestations– see Nursing in Therapy.

First aid

1) lay or sit the patient down, unfasten the belt and collar, provide access to fresh air, complete physical and emotional rest;

2) with systolic blood pressure not less than 100 mm Hg. Art. and heart rate is more than 50 per minute, give a nitroglycerin tablet under the tongue at intervals of 5 minutes. (but no more than 3 times);

3) give an aspirin tablet (325 or 500 mg) to drink;

4) give a propranolol tablet 10–40 mg sublingually;

5) administer intramuscularly: 1 ml of a 2% solution of promedol + 2 ml of a 50% solution of analgin + 1 ml of a 2% solution of diphenhydramine + 0.5 ml of a 1% solution of atropine sulfate;

6) with systolic blood pressure less than 100 mm Hg. Art. 60 mg of prednisolone diluted with 10 ml of saline must be administered intravenously;

7) administer heparin 20,000 units intravenously, and then 5,000 units subcutaneously into the area around the navel;

8) the patient should be transported to the hospital in a lying position on a stretcher.

Pulmonary edema

Clinical manifestations

It is necessary to differentiate pulmonary edema from cardiac asthma.

1. Clinical manifestations of cardiac asthma:

1) frequent shallow breathing;

2) exhalation is not difficult;

3) position of orthopnea;

4) upon auscultation, dry or wheezing sounds.

2. Clinical manifestations of alveolar pulmonary edema:

1) suffocation, bubbling breathing;

2) orthopnea;

3) pallor, cyanosis of the skin, moisture of the skin;

4) tachycardia;

5) secretion of a large amount of foamy, sometimes blood-stained sputum.

First aid

1) give the patient a sitting position, apply tourniquets or tonometer cuffs to the lower extremities. Reassure the patient and provide fresh air;

2) administer 1 ml of a 1% solution of morphine hydrochloride dissolved in 1 ml of saline or 5 ml of a 10% glucose solution;

3) give nitroglycerin 0.5 mg sublingually every 15–20 minutes. (up to 3 times);

4) under blood pressure control, administer 40–80 mg of furosemide intravenously;

5) in case of high blood pressure, inject intravenously 1–2 ml of a 5% solution of pentamine dissolved in 20 ml of physiological solution, 3–5 ml each with an interval of 5 minutes; 1 ml of 0.01% solution of clonidine dissolved in 20 ml of saline solution;

6) establish oxygen therapy - inhalation of humidified oxygen using a mask or nasal catheter;

7) inhale oxygen humidified with 33% ethyl alcohol, or administer 2 ml of a 33% ethyl alcohol solution intravenously;

8) administer 60–90 mg of prednisolone intravenously;

9) if there is no effect of therapy, pulmonary edema increases, or blood pressure drops, artificial ventilation is indicated;

10) hospitalize the patient.

Fainting can occur during prolonged stay in a stuffy room due to lack of oxygen, in the presence of tight clothing that restricts breathing (corset) healthy person. Repeated fainting is a reason to visit a doctor to rule out a serious pathology.

Fainting

Clinical manifestations

1. Short-term loss of consciousness (for 10–30 s.).

2. There is no indication in the medical history of cardiovascular diseases, respiratory systems, gastrointestinal tract, no obstetric-gynecological history.

First aid

1) give the patient’s body a horizontal position (without a pillow) with slightly raised legs;

2) unfasten the belt, collar, buttons;

3) spray your face and chest with cold water;

4) rub the body with dry hands - arms, legs, face;

5) let the patient inhale ammonia vapor;

6) intramuscularly or subcutaneously inject 1 ml of a 10% solution of caffeine, intramuscularly - 1–2 ml of a 25% solution of cordiamine.

Bronchial asthma (attack)

Clinical manifestations– see Nursing in Therapy.

First aid

1) sit the patient down, help him take a comfortable position, unfasten his collar, belt, provide emotional peace and access to fresh air;

2) distraction therapy in the form of a hot foot bath (water temperature at the level of individual tolerance);

3) administer 10 ml of a 2.4% solution of aminophylline and 1–2 ml of a 1% solution of diphenhydramine (2 ml of a 2.5% solution of promethazine or 1 ml of a 2% solution of chloropyramine) intravenously;

4) inhale an aerosol of bronchodilators;

5) with a hormone-dependent form bronchial asthma and information from the patient about a violation of the course of hormone therapy, administer prednisolone in a dose and method of administration corresponding to the main course of treatment.

Asthmatic status

Clinical manifestations– see Nursing in Therapy.

First aid

1) calm the patient, help him take a comfortable position, provide access to fresh air;

2) oxygen therapy with a mixture of oxygen and atmospheric air;

3) if breathing stops - mechanical ventilation;

4) administer rheopolyglucin intravenously in a volume of 1000 ml;

5) administer 10–15 ml of a 2.4% aminophylline solution intravenously during the first 5–7 minutes, then 3–5 ml of a 2.4% aminophylline solution intravenously in an infusion solution or 10 ml 2.4 % solution of aminophylline every hour into a dropper tube;

6) administer 90 mg of prednisolone or 250 mg of hydrocortisone intravenously;

7) administer heparin up to 10,000 units intravenously.

Notes

1. Taking sedatives, antihistamines, diuretics, calcium and sodium supplements (including saline) is contraindicated!

2. Repeated sequential use of bronchodilators is dangerous due to the possibility of death.

Pulmonary hemorrhage

Clinical manifestations

Discharge of bright scarlet foamy blood from the mouth during a cough or with virtually no coughing impulses.

First aid

1) calm the patient down, help him take a semi-sitting position (to facilitate expectoration), forbid him to get up, talk, call a doctor;

2) place an ice pack or cold compress on the chest;

3) give the patient a cold liquid to drink: table salt solution (1 tablespoon of salt per glass of water), nettle decoction;

4) carry out hemostatic therapy: 1–2 ml of 12.5% ​​solution of dicinone intramuscularly or intravenously, 10 ml of 1% solution of calcium chloride intravenously, 100 ml of 5% solution of aminocaproic acid intravenously drip, 1–2 ml 1 % solution of vikasol intramuscularly.

If it is difficult to determine the type of coma (hypo- or hyperglycemic), first aid begins with the administration of a concentrated glucose solution. If the coma is associated with hypoglycemia, then the victim begins to come to his senses, the skin turns pink. If there is no response, then the coma is most likely hyperglycemic. At the same time, clinical data should be taken into account.

Hypoglycemic coma

Clinical manifestations

2. Dynamics of development of a comatose state:

1) feeling of hunger without thirst;

2) anxious anxiety;

3) headache;

4) increased sweating;

5) excitement;

6) stunned;

7) loss of consciousness;

8) convulsions.

3. Absence of symptoms of hyperglycemia (dry skin and mucous membranes, decreased skin turgor, softness eyeballs, smell of acetone from the mouth).

4. Quick positive effect from intravenous administration of a 40% glucose solution.

First aid

1) administer 40–60 ml of 40% glucose solution intravenously;

2) if there is no effect, re-introduce 40 ml of a 40% glucose solution intravenously, as well as 10 ml of a 10% calcium chloride solution intravenously, 0.5–1 ml of a 0.1% solution of adrenaline hydrochloride subcutaneously (in the absence of contraindications );

3) when you feel better, give sweet drinks with bread (to prevent a relapse);

4) patients are subject to hospitalization:

a) when a hypoglycemic state occurs for the first time;

b) if hypoglycemia occurs in a public place;

c) if emergency medical care measures are ineffective.

Depending on the condition, hospitalization is carried out on a stretcher or on foot.

Hyperglycemic (diabetic) coma

Clinical manifestations

1. History of diabetes mellitus.

2. Development of coma:

1) lethargy, extreme fatigue;

2) loss of appetite;

3) uncontrollable vomiting;

4) dry skin;

6) frequent excessive urination;

7) decreased blood pressure, tachycardia, heart pain;

8) adynamia, drowsiness;

9) stupor, coma.

3. The skin is dry, cold, lips are dry, cracked.

4. The tongue is raspberry colored with a dirty gray coating.

5. The smell of acetone in the exhaled air.

6. Sharply reduced tone of the eyeballs (soft to the touch).

First aid

Sequencing:

1) carry out rehydration using 0.9% sodium chloride solution intravenously at a rate of 200 ml per 15 minutes. under the control of blood pressure levels and spontaneous breathing (cerebral edema is possible if rehydration is too rapid);

2) emergency hospitalization in the intensive care unit of a multidisciplinary hospital, bypassing the emergency department. Hospitalization is carried out on a stretcher, lying down.

Acute stomach

Clinical manifestations

1. Abdominal pain, nausea, vomiting, dry mouth.

2. Pain on palpation of the anterior abdominal wall.

3. Symptoms of peritoneal irritation.

4. The tongue is dry, coated.

5. Low-grade fever, hyperthermia.

First aid

Urgently deliver the patient to the surgical hospital on a stretcher, in a position comfortable for him. Pain relief, drinking water and food are prohibited!

Acute abdomen and similar conditions can occur with a variety of pathologies: diseases digestive system, gynecological, infectious pathologies. The main principles of first aid in these cases are: cold, hunger and rest.

Gastrointestinal bleeding

Clinical manifestations

1. Paleness of the skin and mucous membranes.

2. Vomiting blood or “coffee grounds.”

3. Black tarry stools or scarlet blood (with bleeding from the rectum or anus).

4. The stomach is soft. There may be pain on palpation in the epigastric region. There are no symptoms of peritoneal irritation, the tongue is moist.

5. Tachycardia, hypotension.

6. History – peptic ulcer, gastrointestinal cancer, liver cirrhosis.

First aid

1) give the patient ice in small pieces;

2) with worsening hemodynamics, tachycardia and a decrease in blood pressure - polyglucin (reopolyglucin) intravenously until systolic blood pressure stabilizes at 100–110 mm Hg. Art.;

3) administer 60–120 mg of prednisolone (125–250 mg of hydrocortisone) – add to the infusion solution;

4) administer up to 5 ml of a 0.5% dopamine solution intravenously in an infusion solution in case of a critical drop in blood pressure that cannot be corrected by infusion therapy;

5) cardiac glycosides according to indications;

6) emergency delivery to a surgical hospital while lying on a stretcher with the head end down.

Renal colic

Clinical manifestations

1. Paroxysmal pain in the lower back, unilateral or bilateral, radiating to the groin, scrotum, labia, front or inner thigh.

2. Nausea, vomiting, bloating with retention of stool and gas.

3. Dysuric disorders.

4. Motor restlessness, the patient is looking for a position in which the pain will ease or stop.

5. The abdomen is soft, slightly painful along the ureters or painless.

6. Tapping on the lower back in the kidney area is painful, symptoms of peritoneal irritation are negative, the tongue is wet.

7. History of kidney stones.

First aid

1) administer 2–5 ml of a 50% solution of analgin intramuscularly or 1 ml of a 0.1% solution of atropine sulfate subcutaneously, or 1 ml of a 0.2% solution of platiphylline hydrotartrate subcutaneously;

2) place a hot heating pad on the lumbar area or (in the absence of contraindications) place the patient in hot bath. Do not leave him alone, monitor his general well-being, pulse, respiratory rate, blood pressure, skin color;

3) hospitalization: with the first attack, with hyperthermia, failure to stop the attack at home, with a repeated attack within 24 hours.

Renal colic is a complication of urolithiasis that occurs due to metabolic disorders. The cause of the painful attack is the displacement of the stone and its entry into the ureters.

Anaphylactic shock

Clinical manifestations

1. Relationship of the condition to the administration of a drug, vaccine, intake of a specific food, etc.

2. Feeling of fear of death.

3. Feeling of lack of air, chest pain, dizziness, tinnitus.

4. Nausea, vomiting.

5. Cramps.

6. Severe pallor, cold sticky sweat, urticaria, soft tissue swelling.

7. Tachycardia, thready pulse, arrhythmia.

8. Severe hypotension, diastolic blood pressure is not determined.

9. Comatose state.

First aid

Sequencing:

1) in case of shock caused by intravenous administration of an allergen drug, leave the needle in the vein and use it for emergency anti-shock therapy;

2) stop administration immediately medicinal substance which caused the development of anaphylactic shock;

3) give the patient a functionally advantageous position: raise the limbs at an angle of 15°. Turn your head to the side, if you lose consciousness, push your lower jaw forward, remove dentures;

4) carry out oxygen therapy with 100% oxygen;

5) administer intravenously 1 ml of a 0.1% solution of adrenaline hydrochloride, diluted in 10 ml of a 0.9% solution of sodium chloride; the same dose of adrenaline hydrochloride (but without dilution) can be administered under the root of the tongue;

6) start administering polyglucin or other infusion solution as a bolus after stabilization of systolic blood pressure by 100 mm Hg. Art. - continue infusion therapy drip;

7) introduce 90–120 mg of prednisolone (125–250 mg of hydrocortisone) into the infusion system;

8) introduce 10 ml of 10% calcium chloride solution into the infusion system;

9) if there is no effect from the therapy, repeat the administration of adrenaline hydrochloride or administer 1–2 ml of a 1% mesatone solution intravenously in a stream;

10) for bronchospasm, administer 10 ml of a 2.4% solution of aminophylline intravenously;

11) for laryngospasm and asphyxia - conicotomy;

12) if the allergen was introduced intramuscularly or subcutaneously or an anaphylactic reaction occurred in response to an insect bite, it is necessary to inject the injection or bite site with 1 ml of a 0.1% solution of adrenaline hydrochloride diluted in 10 ml of a 0.9% solution of sodium chloride ;

13) if the allergen enters the body orally, it is necessary to rinse the stomach (if the patient’s condition allows);

14) for convulsive syndrome, administer 4–6 ml of 0.5% diazepam solution;

15) in case of clinical death, perform cardiopulmonary resuscitation.

Each treatment room must have a first aid kit for providing first aid for anaphylactic shock. Most often, anaphylactic shock develops during or after the administration of biological products and vitamins.

Quincke's edema

Clinical manifestations

1. Association with an allergen.

2. Itchy rash on various parts of the body.

3. Swelling of the back of the hands, feet, tongue, nasal passages, oropharynx.

4. Puffiness and cyanosis of the face and neck.

6. Mental agitation, motor restlessness.

First aid

Sequencing:

1) stop introducing the allergen into the body;

2) administer 2 ml of a 2.5% solution of promethazine, or 2 ml of a 2% solution of chloropyramine, or 2 ml of a 1% solution of diphenhydramine intramuscularly or intravenously;

3) administer 60–90 mg of prednisolone intravenously;

4) administer 0.3–0.5 ml of a 0.1% solution of adrenaline hydrochloride subcutaneously or, diluting the drug in 10 ml of a 0.9% solution of sodium chloride, intravenously;

5) inhale bronchodilators (fenoterol);

6) be ready to perform conicotomy;

7) hospitalize the patient.

All of us, unfortunately, may find ourselves in a situation where our or someone else’s life is in danger. If, while walking down the street, you notice a person who feels ill, you should not walk past. Perhaps he has an emergency condition and simply needs emergency medical care.

What condition is considered urgent?

A danger to human health and life can arise at the most inopportune moment and in the most inopportune place. A condition in which a person experiences serious illness is called an emergency.

There are two types of emergencies:

• External – caused by the negative impact of environmental factors;
• Internal - occur in the human body, caused by pathology.

Sometimes external emergencies can trigger internal ones.

The most common reasons for calling an emergency ambulance are:

• Traumatic injuries and large blood loss;
• Fainting;
• Poisoning (food, toxic);
• Heart attack;
• Stroke.

Whatever the emergency, seconds count. Timely and qualified provision of medical care is very important.

Who will help

There are several types of emergency care:

1. First aid - can be provided by a person who does not have a medical education (for example, a rescuer, fireman, police, or just a passerby who knows how to provide first aid);
2. First aid - it is usually provided by junior medical personnel (for example, a nurse);
3. First medical aid is provided by general practitioners (emergency doctors);
4. Specialized assistance is provided by doctors of a certain specialty.
5. In case of emergency, all types of assistance can be provided in stages.

Legal regulation

At the legislative level, the provision of emergency medical care is regulated by Federal Law No. 323.

Paragraph 10 of Article 83 of this regulatory document talks about the obligation to provide emergency medical care to health care organizations free of charge.

It is said that reimbursement of expenses is carried out on the basis of a state guarantee program for the provision of free medical care.

Article 124 of the Criminal Code of the Russian Federation provides for punishment in case of failure to provide assistance to a sick person who is obliged to do so.

Capital punishment in the form of deprivation of the right to engage in certain types of activities for up to three years and forced labor for a period of no more than four years - in the event of the death of a patient who was not provided emergency help without good reason.

First aid

The patient’s speedy recovery depends on the correct identification of an emergency condition and the provision of first aid.

Fainting is a loss of consciousness that occurs when the circulatory system of the brain is disrupted. It is necessary to unfasten the constricting clothing, feel the pulse, lay the victim on a flat surface on his side, put a wet towel on his head, and wait for the doctors to arrive.

Myocardial infarction is a disruption of the blood supply to the heart. If the patient is conscious, help him take a semi-sitting position, give aspirin, provide oxygen access and call an ambulance.

Stroke – damage to the functioning of the central nervous system. Urgent call for specialized help, if the patient is conscious, lay him on his side, control the pressure, ensure maximum rest.

Poisoning is a disorder of the body due to the ingestion of toxic substances or poison. When leaving, it is necessary to rinse the stomach with plenty of water, give activated charcoal, ensure rest and call a doctor.

If there is a large loss of blood, it is necessary to wash the wound with hydrogen peroxide or brilliant green, bandage the artery above the location of the wound, and give the patient a comfortable position.

Aching tooth

Toothache can also take you by surprise. If not stopped in time, it not only causes discomfort, but can lead to serious consequences ( inflammatory processes, fluxes). Therefore, in dentistry, doctors are on duty around the clock.

Emergency assistance in the event of a threat to life is provided by the dentist on duty free of charge.

How emergency care should be provided by doctors was written in detail in his reference book by Evgeniy Ivanovich Chazova.

Emergency assistance has existed at all times, because it is simply impossible to do without this type of service. Soviet legislation established its own rules for providing emergency assistance.

Since then, the Ministry of Health has changed some aspects of the regulations, but medical workers still stand guard over our health and lives.

Read other articles on our website!

SUDDEN DEATH

Diagnostics. Lack of consciousness and pulse in the carotid arteries, a little later - cessation of breathing.

During CPR, ECP indicates ventricular fibrillation (in 80% of cases), asystole or electromechanical dissociation (in 10-20% of cases). If it is impossible to urgently register an ECG, they are guided by the manifestations of the onset of clinical death and the reaction to CPR.

Ventricular fibrillation develops suddenly, symptoms appear sequentially: disappearance of the pulse in the carotid arteries and loss of consciousness, single tonic contraction of skeletal muscles, disturbances and respiratory arrest. The reaction to timely CPR is positive, and to cessation of CPR is a quick negative reaction.

With advanced SA or AV blockade, symptoms develop relatively gradually: confusion => motor agitation => moaning => tonic-clonic convulsions => breathing problems (MAS syndrome). When performing closed cardiac massage, there is a rapid positive effect that persists for some time after CPR is stopped.

Electromechanical dissociation in massive pulmonary embolism occurs suddenly (often at a moment of physical stress) and is manifested by cessation of breathing, absence of consciousness and pulse in the carotid arteries, and severe cyanosis of the skin of the upper half of the body. swelling of the neck veins. When CPR is started in a timely manner, signs of its effectiveness are determined.

Electromechanical dissociation during myocardial rupture, cardiac tamponade develops suddenly (often after severe anginal syndrome), without convulsive syndrome, signs of CPR effectiveness are completely absent. Hypostatic spots quickly appear on the back.

Electromechanical dissociation due to other causes (hypovolemia, hypoxia, tension pneumothorax, drug overdose, increasing cardiac tamponade) does not occur suddenly, but develops against the background of progression of the corresponding symptoms.

Urgent Care :

1. In case of ventricular fibrillation and immediate defibrillation is impossible:

Apply a precordial blow: Cover the xiphoid process with two fingers to protect it from damage. It is located at the bottom of the sternum, where the lower ribs meet, and with a sharp blow can break off and injure the liver. Apply a pericardial blow with the edge of your clenched fist slightly above the xiphoid process covered by your fingers. It looks like this: with two fingers of one hand you cover the xiphoid process, and with the fist of the other hand you strike (with the elbow of the hand directed along the victim’s torso).

After this, check the pulse in the carotid artery. If the pulse does not appear, it means that your actions are not effective.

There is no effect - immediately begin CPR, ensure defibrillation is possible as soon as possible.

2. Conduct closed cardiac massage at a frequency of 90 per minute with a compression-decompression ratio of 1:1: the active compression-decompression method (using a cardiopump) is more effective.

3. WALKING in an accessible way (the ratio of massage movements and breathing is 5:1, and when working with one doctor - 15:2), ensure the patency of the airways (throw back the head, extend the lower jaw, insert an air duct, according to indications - sanitize the airways);

Use 100% oxygen:

Intubate the trachea (no more than 30 s);

Do not interrupt cardiac massage and mechanical ventilation for more than 30 seconds.

4. Catheterize the central or peripheral vein.

5. Adrenaline 1 mg every 3 minutes of CPR (method of administration hereinafter - see note).

6. As early as possible - defibrillation 200 J;

No effect - defibrillation 300 J:

No effect - defibrillation 360 J:

No effect - see point 7.

7. Act according to the scheme: drug - cardiac massage and mechanical ventilation, after 30-60 s - defibrillation 360 J:

Lidocaine 1.5 mg/kg - defibrillation 360 J:

There is no effect - after 3 minutes, repeat the lidocaine injection at the same dose and defibrillation 360 J:

No effect - ornid 5 mg/kg - defibrillation 360 J;

There is no effect - after 5 minutes, repeat the injection of Ornid at a dose of 10 mg/kg - defibrillation 360 J;

No effect - novocainamide 1 g (up to 17 mg/kg) - defibrillation 360 J;

No effect - magnesium sulfate 2 g - defibrillation 360 J;

In pauses between shocks, perform closed cardiac massage and mechanical ventilation.

8. With asystole:

If it is impossible to accurately assess the electrical activity of the heart (do not exclude the atonic stage of ventricular fibrillation), act. as in ventricular fibrillation (items 1-7);

If asystole is confirmed in two ECG leads, perform steps. 2-5;

No effect - atropine 1 mg every 3-5 minutes until an effect is achieved or a total dose of 0.04 mg/kg is achieved;

EX as early as possible;

Adjust possible reason asystole (hypoxia, hypo- or hyperkalemia, acidosis, drug overdose, etc.);

Administration of 240-480 mg of aminophylline may be effective.

9. With electromechanical dissociation:

Execute paragraph 2-5;

Establish and correct its possible cause (massive pulmonary embolism - see relevant recommendations: cardiac tamponade - pericardiocentesis).

10. Monitor vital functions (cardiac monitor, pulse oximeter).

11. Hospitalize after possible stabilization of the condition.

12. CPR can be stopped if:

As the procedure progressed, it became clear that CPR was not indicated:

Persistent asystole that is not amenable to medication, or multiple episodes of asystole are observed:

Using all available methods, there is no evidence that CPR is effective within 30 minutes.

13. CPR may not be started:

In the terminal stage of an incurable disease (if the futility of CPR is documented in advance);

If more than 30 minutes have passed since the cessation of blood circulation;

If the patient has previously documented refusal to perform CPR.

After defibrillation: asystole, ongoing or recurrent ventricular fibrillation, skin burn;

During mechanical ventilation: gastric overfilling with air, regurgitation, aspiration of gastric contents;

During tracheal intubation: laryngo- and bronchospasm, regurgitation, damage to the mucous membranes, teeth, esophagus;

With closed heart massage: fracture of the sternum, ribs, lung damage, tension pneumothorax;

During puncture of the subclavian vein: bleeding, puncture of the subclavian artery, lymphatic duct, air embolism, tension pneumothorax:

With intracardiac injection: administration of drugs into the myocardium, damage coronary arteries, hemotamponade, lung injury, pneumothorax;

Respiratory and metabolic acidosis;

Hypoxic coma.

Note. In case of ventricular fibrillation and the possibility of immediate (within 30 s) defibrillation - defibrillation 200 J, then proceed according to paragraphs. 6 and 7.

Administer all medications intravenously quickly during CPR.

When using a peripheral vein, mix the drugs with 20 ml of isotonic sodium chloride solution.

In the absence of venous access, adrenaline, atropine, lidocaine (increasing the recommended dose by 2 times) should be injected into the trachea in 10 ml of isotonic sodium chloride solution.

Intracardiac injections (with a thin needle, with strict adherence to the injection technique and control) are permissible in exceptional cases, when it is absolutely impossible to use other routes of drug administration.

Sodium bicarbonate 1 mmol/kg (4% solution - 2 ml/kg), then 0.5 mmol/kg every 5-10 minutes, used for very long CPR or in cases of hyperkalemia, acidosis, overdose of tricyclic antidepressants, hypoxic lactic acidosis preceding cessation of blood circulation ( exclusively under conditions of adequate mechanical ventilation1).

Calcium supplements are indicated only for severe initial hyperkalemia or overdose of calcium antagonists.

For treatment-resistant ventricular fibrillation, reserve drugs are amiodarone and propranolol.

In case of asystole or electromechanical dissociation after tracheal intubation and administration of drugs, if the cause cannot be eliminated, decide on cessation of resuscitation measures, taking into account the time elapsed from the onset of circulatory arrest.

CARDIOLOGICAL EMERGENCIES TACHYARHYTHMIAS

Diagnostics. Severe tachycardia, tachyarrhythmia.

Differential diagnosis- according to ECG. It is necessary to distinguish between non-paroxysmal and paroxysmal tachycardias: tachycardias with normal duration of the OK8 complex (supraventricular tachycardia, atrial fibrillation and flutter) and tachycardias with a wide 9K8 complex on the ECG (supraventricular tachycardia, fibrillation, atrial flutter with transient or permanent blockade of the P1ca bundle branch: antidromic supraventricular tachycardias and ; atrial fibrillation with IGV syndrome; ventricular tachycardia).

Urgent Care

Emergency restoration of sinus rhythm or correction of heart rate is indicated for tachyarrhythmias complicated by acute circulatory disorders, with the threat of cessation of blood circulation, or with repeated paroxysms of tachyarrhythmias with a known method of suppression. In other cases, intensive monitoring and planned treatment(emergency hospitalization).

1. If blood circulation stops, perform CPR according to the “Sudden Death” recommendations.

2. Shock or pulmonary edema (caused by tachyarrhythmia) are absolute vital indications for EIT:

Carry out oxygen therapy;

If the patient’s condition allows, then premedicate (fentanyl 0.05 mg or promedol 10 mg intravenously);

Introduce medicinal sleep (diazepam 5 mg intravenously and 2 mg every 1-2 minutes until falling asleep);

Monitor heart rate:

Carry out EIT (for atrial flutter, supraventricular tachycardia, start with 50 J; for atrial fibrillation, monomorphic ventricular tachycardia - with 100 J; for polymorphic ventricular tachycardia - with 200 J):

If the patient’s condition allows, synchronize the electrical impulse during EIT with the K wave on the ECL

Use well-moistened pads or gel;

At the moment of delivering the shock, press the electrodes firmly against the chest wall:

Apply the shock as the patient exhales;

Follow safety regulations;

There is no effect - repeat the EIT, doubling the discharge energy:

There is no effect - repeat EIT with a discharge of maximum energy;

There is no effect - administer an antiarrhythmic drug indicated for this arrhythmia (see below) and repeat EIT with a maximum energy discharge.

3. In case of clinically significant circulatory disorders (arterial hypotension, anginal pain, increasing heart failure or neurological symptoms) or in case of repeated paroxysms of arrhythmia with a known method of suppression, carry out emergency drug therapy. If there is no effect, the condition worsens (and in the cases indicated below - and as an alternative drug treatment) - EIT (item 2).

3.1. With paroxysm of reciprocal supraventricular tachycardia:

Carotid sinus massage (or other vagal techniques);

No effect - administer ATP 10 mg intravenously with a push:

No effect - after 2 minutes ATP 20 mg intravenously in a push:

No effect - after 2 minutes verapamil 2.5-5 mg intravenously:

No effect - after 15 minutes verapamil 5-10 mg intravenously;

A combination of ATP or verapamil administration with vagal techniques may be effective:

No effect - after 20 minutes novocainamide 1000 mg (up to 17 mg/kg) intravenously at a rate of 50-100 mg/min (with a tendency to arterial hypotension - in one syringe with 0.25-0.5 ml of 1% mesatone solution or 0.1-0.2 ml of 0.2% norepinephrine solution).

3.2. For paroxysmal atrial fibrillation to restore sinus rhythm:

Novocainamide (clause 3.1);

With a high initial heart rate: first, 0.25-0.5 mg of digoxin (strophanthin) intravenously and after 30 minutes - 1000 mg of novocainamide. To reduce heart rate:

Digoxin (strophantine) 0.25-0.5 mg, or verapamil 10 mg intravenously slowly or 80 mg orally, or digoxin (strophantine) intravenously and verapamil orally, or anaprilin 20-40 mg sublingually or orally.

3.3. For paroxysmal atrial flutter:

If EIT is not possible, reduce heart rate with digoxin (strophanthin) and (or) verapamil (clause 3.2);

To restore sinus rhythm, novocainamide may be effective after preliminary administration of 0.5 mg of digoxin (strophanthin).

3.4. In case of paroxysm of atrial fibrillation against the background of IPU syndrome:

Slow intravenous novocainamide 1000 mg (up to 17 mg/kg), or ami-darone 300 mg (up to 5 mg/kg). or rhythmylene 150 mg. or aimalin 50 mg: either EIT;

Cardiac glycosides. β-adrenergic receptor blockers, calcium antagonists (verapamil, diltazem) are contraindicated!

3.5. During paroxysm of antidromic reciprocal AV tachycardia:

Intravenously slowly novocainamide, or amiodarone, or ajmaline, or rhythmylene (section 3.4).

3.6. In case of takiarigmia against the background of CVS, to reduce heart rate:

Intravenously slowly 0.25 mg of digoxin (strophantine).

3.7. With paroxysm of ventricular tachycardia:

Lidocaine 80-120 mg (1-1.5 mg/kg) and every 5 minutes 40-60 mg (0.5-0.75 mg/kg) intravenously slowly until the effect or a total dose of 3 mg/kg is reached:

No effect - EIT (item 2). or procainamide. or amiodarone (section 3.4);

No effect - EIT or magnesium sulfate 2 g intravenously very slowly:

No effect - EIT or Ornid 5 mg/kg intravenously (over 5 minutes);

No effect - EIT or after 10 minutes Ornid 10 mg/kg intravenously (over 10 minutes).

3.8. With bidirectional fusiform tachycardia.

EIT or slowly introduce 2 g of magnesium sulfate intravenously (if necessary, magnesium sulfate is reintroduced after 10 minutes).

3.9. In case of paroxysm of tachycardia of unknown origin with wide complexes 9K5 on the ECG (if there are no indications for EIT), administer lidocaine intravenously (section 3.7). no effect - ATP (clause 3.1) or EIT, no effect - novocainamide (clause 3.4) or EIT (clause 2).

4. In all cases of acute cardiac arrhythmia (except for repeated paroxysms with restored sinus rhythm), emergency hospitalization is indicated.

5. Constantly monitor heart rate and conduction.

Cessation of blood circulation (ventricular fibrillation, asystole);

MAS syndrome;

Acute heart failure (pulmonary edema, arrhythmic shock);

Arterial hypotension;

Respiratory failure when administered narcotic analgesics or diazepam;

Skin burns during EIT:

Thromboembolism after EIT.

Note. Emergency treatment Arrhythmias should be carried out only according to the indications given above.

If possible, the cause of arrhythmia and its supporting factors should be influenced.

Emergency EIT with a heart rate less than 150 per minute is usually not indicated.

In case of severe tachycardia and there are no indications for urgent restoration of sinus rhythm, it is advisable to reduce heart rate.

If there are additional indications, potassium and magnesium supplements should be used before administering antiarrhythmic drugs.

For paroxysmal atrial fibrillation, the administration of 200 mg of fenkarol orally can be effective.

An accelerated (60-100 per minute) idioventricular rhythm or rhythm from the AV junction is usually a replacement, and the use of antiarrhythmic drugs in these cases is not indicated.

Emergency care for repeated, habitual paroxysms of tachyarrhythmia should be provided taking into account the effectiveness of treatment of previous paroxysms and factors that can change the patient’s response to the introduction of antiarrhythmic drugs that helped him before.

BRADYARHYTHMIAS

Diagnostics. Severe (heart rate less than 50 per minute) bradycardia.

Differential diagnosis- according to ECG. It is necessary to differentiate sinus bradycardia, SA node arrest, SA and AV blockade: distinguish AV blockade by degree and level (distal, proximal); in the presence of an implanted pacemaker, it is necessary to evaluate the effectiveness of stimulation at rest, with changes in body position and load.

Urgent Care . Intensive therapy is necessary if bradycardia (heart rate less than 50 per minute) causes MAS syndrome or its equivalents, shock, pulmonary edema, arterial hypotension, angina pain, or a progressive decrease in heart rate or an increase in ectopic ventricular activity is observed.

2. In case of MAS syndrome or bradycardia causing acute heart failure, arterial hypotension, neurological symptoms, anginal pain or with a progressive decrease in heart rate or increase in ectopic ventricular activity:

Place the patient with the lower limbs elevated at an angle of 20° (if there is no pronounced congestion in the lungs):

Carry out oxygen therapy;

If necessary (depending on the patient’s condition), closed heart massage or rhythmic tapping on the sternum (“fist rhythm”);

Administer atropine 1 mg intravenously over 3-5 minutes until the effect is achieved or a total dose of 0.04 mg/kg is achieved;

No effect - immediate endocardial percutaneous or transesophageal pacemaker:

There is no effect (or there is no possibility of ECS) - intravenous slow injection of 240-480 mg of aminophylline;

No effect - dopamine 100 mg or adrenaline 1 mg in 200 ml of 5% glucose solution intravenously; Gradually increase the infusion rate until a minimum sufficient heart rate is achieved.

3. Constantly monitor heart rate and conduction.

4. Hospitalize after possible stabilization of the condition.

Main dangers in complications:

Asystole;

Ectopic ventricular activity (up to fibrillation), including after the use of adrenaline, dopamine. atropine;

Acute heart failure (pulmonary edema, shock);

Arterial hypotension:

Anginal pain;

Impossibility or ineffectiveness of pacemaker:

Complications of endocardial pacemaker (ventricular fibrillation, right ventricular perforation);

Pain during transesophageal or percutaneous pacemaker.

UNSTABLE ANGINA

Diagnostics. The appearance of frequent or severe anginal attacks (or their equivalents) for the first time, a change in the course of previously existing angina, the resumption or appearance of angina in the first 14 days of the development of myocardial infarction, or the first appearance of anginal pain at rest.

There are risk factors for developing or clinical manifestations IHD. Changes in the ECG, even at the height of the attack, may be vague or absent!

Differential diagnosis. In most cases - with prolonged exertional angina, acute myocardial infarction, cardialgia. extracardiac pain.

Urgent Care

1. Shown:

Nitroglycerin (tablets or aerosol 0.4-0.5 mg sublingually repeatedly);

Oxygen therapy;

Correction blood pressure and heart rate:

Propranolol (anaprilin, inderal) 20-40 mg orally.

2. For anginal pain (depending on its severity, age and condition of the patient);

Morphine up to 10 mg or neuroleptanalgesia: fentanyl 0.05-0.1 mg or promedol 10-20 mg with 2.5-5 mg droperidol intravenously in divided doses:

In case of insufficient analgesia - 2.5 g of analgin intravenously, and in case of high blood pressure - 0.1 mg of clonidine.

5000 units of heparin intravenously. and then dropwise 1000 units/hour.

5. Hospitalize after possible stabilization of the condition. Main dangers and complications:

Acute myocardial infarction;

Acute disturbances of heart rhythm or conduction (including sudden death);

Incomplete elimination or recurrence of anginal pain;

Arterial hypotension (including drug-induced);

Acute heart failure:

Breathing disorders when administered narcotic analgesics.

Note. Emergency hospitalization is indicated, regardless of the presence of changes on the ECG, in intensive care units (wards), departments for the treatment of patients with acute myocardial infarction.

It is necessary to ensure constant monitoring of heart rate and blood pressure.

To provide emergency care (in the first hours of the disease or in case of complications), catheterization of a peripheral vein is indicated.

For recurrent anginal pain or moist rales in the lungs, nitroglycerin should be administered intravenously.

For the treatment of unstable angina, the rate of intravenous heparin administration must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared with its normal value. It is much more convenient to use low molecular weight heparin enoxaparin (Clexane). 30 mg of Clexane is administered intravenously as a bolus, after which the drug is prescribed subcutaneously at 1 mg/kg 2 times a day for 3-6 days.

If traditional narcotic analgesics are not available, then 1-2 mg of butorphanol or 50-100 mg of tramadol with 5 mg of droperidol and (or) 2.5 g of analgin with 5 mg of diaepam can be prescribed intravenously slowly or in fractions.

MYOCARDIAL INFARCTION

Diagnostics. Characteristic are chest pain (or its equivalents) radiating to the left (sometimes to the right) shoulder, forearm, scapula, and neck. lower jaw, epigastric region; disturbances of heart rhythm and conduction, instability of blood pressure: the response to taking nitroglycerin is incomplete or absent. Other variants of the onset of the disease are less common: asthmatic (cardiac asthma, pulmonary edema). arrhythmic (fainting, sudden death, MAS syndrome). cerebrovascular (acute neurological symptoms), abdominal (pain in the epigastric region, nausea, vomiting), asymptomatic (weakness, vague sensations in chest). There is a history of risk factors or signs of coronary artery disease, the appearance for the first time or a change in habitual anginal pain. Changes in the ECG (especially in the first hours) may be vague or absent! 3-10 hours after the onset of the disease - a positive test with troponin-T or I.

Differential diagnosis. In most cases - with prolonged angina, unstable angina, cardialgia. extracardiac pain. PE, acute organ diseases abdominal cavity(pancreatitis, cholecystitis, etc.), dissecting aortic aneurysm.

Urgent Care

1. Shown:

Physical and emotional peace:

Nitroglycerin (tablets or aerosol 0.4-0.5 mg sublingually repeatedly);

Oxygen therapy;

Correction of blood pressure and heart rate;

Acetylsalicylic acid 0.25 g (chew);

Propranolol 20-40 mg orally.

2. For pain relief (depending on the severity of pain, the patient’s age, his condition):

Morphine up to 10 mg or neuroleptanalgesia: fentanyl 0.05-0.1 mg or promedol 10-20 mg with 2.5-5 mg droperidol intravenously in fractions;

In case of insufficient analgesia - 2.5 g of analgin intravenously, and against the background of high blood pressure - 0.1 mg of clonidine.

3. To restore coronary blood flow:

In case of transmural myocardial infarction with elevation of the 8T segment on the ECG (in the first 6, and in case of recurrent pain - up to 12 hours from the onset of the disease), administer streptokinase 1,500,000 IU intravenously over 30 minutes as early as possible:

In case of subendocardial myocardial infarction with depression of the 8T segment on the ECG (or the impossibility of thrombolytic therapy), administer 5000 units of heparin intravenously as a bolus and then drip as soon as possible.

4. Constantly monitor heart rate and conduction.

5. Hospitalize after possible stabilization of the condition.

Main dangers and complications:

Acute disturbances of heart rhythm and conduction up to sudden death (ventricular fibrillation), especially in the first hours of myocardial infarction;

Recurrence of anginal pain;

Arterial hypotension (including drug-induced);

Acute heart failure (cardiac asthma, pulmonary edema, shock);

Arterial hypotension; allergic, arrhythmic, hemorrhagic complications with the administration of streptokinase;

Breathing disorders due to the administration of narcotic analgesics;

Myocardial rupture, cardiac tamponade.

Note. To provide emergency care (in the first hours of the disease or when complications develop), catheterization of a peripheral vein is indicated.

For recurrent anginal pain or moist rales in the lungs, nitroglycerin should be administered intravenously.

At increased risk development of allergic complications, before prescribing streptokinase, administer 30 mg of prednisolone intravenously. When conducting thrombolytic therapy, ensure control of heart rate and basic hemodynamic indicators, readiness for correction possible complications(availability of a defibrillator, ventilator).

For the treatment of subendocardial (with depression of the 8T segment and without a pathological O wave) myocardial infarction, the rate of intravenous administration of hegyurin must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared with its normal value. It is much more convenient to use low molecular weight heparin enoxaparin (Clexane). 30 mg of Clexane is administered intravenously as a bolus, after which the drug is prescribed subcutaneously at 1 mg/kg 2 times a day for 3-6 days.

If traditional narcotic analgesics are not available, then 1-2 mg of butorphanol or 50-100 mg of tramadol with 5 mg of droperidol and (or) 2.5 g of analgin with 5 mg of diaepam can be prescribed intravenously slowly or in fractions.

CARDIOGENIC PULMONARY EDEMA

Diagnostics. Characteristic: suffocation, shortness of breath, worsening in a lying position, which forces patients to sit up: tachycardia, acrocyanosis. overhydration of tissues, inspiratory shortness of breath, dry wheezing, then moist rales in the lungs, copious foamy sputum, ECG changes (hypertrophy or overload of the left atrium and ventricle, blockade of the left branch of the Pua's bundle, etc.).

History of myocardial infarction, heart defect or other heart disease. hypertension, chronic heart failure.

Differential diagnosis. In most cases, cardiogenic pulmonary edema is differentiated from non-cardiogenic (with pneumonia, pancreatitis, cerebrovascular accident, chemical damage to the lungs, etc.), pulmonary embolism, and bronchial asthma.

Urgent Care

1. General activities:

Oxygen therapy;

Heparin 5000 units intravenous bolus:

Heart rate correction (if the heart rate is more than 150 per 1 min - EIT; if the heart rate is less than 50 per 1 min - ECS);

In case of excessive foam formation, defoaming (inhalation of a 33% ethyl alcohol solution or intravenously 5 ml of a 96% ethyl alcohol solution and 15 ml of a 40% glucose solution), in extremely severe (1) cases, 2 ml of a 96% ethyl alcohol solution is injected into the trachea.

2. With normal blood pressure:

Complete step 1;

Sit the patient with lower limbs down;

Nitroglycerin, tablets (preferably aerosol) 0.4-0.5 mg sublingually again after 3 minutes or up to 10 mg intravenously slowly in fractions or intravenously in 100 ml of isotonic sodium chloride solution, increasing the rate of administration from 25 mcg/min until effect by controlling blood pressure:

Diazepam up to 10 mg or morphine 3 mg intravenously in fractions until the effect is achieved or a total dose of 10 mg is reached.

3. When arterial hypertension:

Complete step 1;

Sit the patient down with lower limbs down:

Nitroglycerin, tablets (preferably aerosol) 0.4-0.5 mg under the tongue once;

Furosemide (Lasix) 40-80 mg intravenously;

Nitroglycerin intravenously (item 2) or sodium nitroprusside 30 mg in 300 ml of 5% glucose solution intravenously, gradually increasing the rate of infusion of the drug from 0.3 mcg/(kg x min) until the effect is obtained, controlling blood pressure, or pentamin to 50 mg intravenously in fractions or drips:

Intravenously up to 10 mg of diazepam or up to 10 mg of morphine (item 2).

4. In case of severe arterial hypotension:

Follow step 1:

Lay the patient down, raising the head of the bed;

Dopamine 200 mg in 400 ml of 5% glucose solution intravenously, increasing the infusion rate from 5 mcg/(kg x min) until blood pressure is stabilized at a minimum sufficient level;

If it is impossible to stabilize blood pressure, additionally prescribe norepinephrine hydrotartrate 4 mg in 200 ml of 5-10% glucose solution, increasing the infusion rate from 0.5 mcg/min until blood pressure is stabilized at a minimum sufficient level;

If blood pressure increases, accompanied by increasing pulmonary edema, additionally nitroglycerin is given intravenously (item 2);

Furosemide (Lasix) 40 mg IV after blood pressure has stabilized.

5. Monitor vital functions (cardiac monitor, pulse oximeter).

6. Hospitalize after possible stabilization of the condition. Main dangers and complications:

Fulminant form of pulmonary edema;

Airway obstruction by foam;

Respiratory depression;

Tachyarrhythmia;

Asystole;

Anginal pain:

Increased pulmonary edema with increased blood pressure.

Note. The minimum sufficient blood pressure should be understood as a systolic pressure of about 90 mmHg. Art. provided that the increase in blood pressure is accompanied by clinical signs improving the perfusion of organs and tissues.

Eufillin for cardiogenic pulmonary edema is an adjuvant and may be indicated for bronchospasm or severe bradycardia.

Glucocorticoid hormones are used only for respiratory distress syndrome (aspiration, infection, pancreatitis, inhalation of irritants, etc.).

Cardiac glycosides (strophanthin, digoxin) can be prescribed only for moderate congestive heart failure in patients with tachysystolic form of atrial fibrillation (flutter).

At aortic stenosis, hypertrophic cardiomyopathy, cardiac tamponade, nitroglycerin and other peripheral vasodilators are relatively contraindicated.

Creating positive end-expiratory pressure is effective.

To prevent recurrence of pulmonary edema in patients with chronic heart failure, ACE inhibitors (captopril) are useful. When captopril is first prescribed, treatment should begin with a test dose of 6.25 mg.

CARDIOGENIC SHOCK

Diagnostics. A marked decrease in blood pressure combined with signs of impaired blood supply to organs and tissues. Systolic blood pressure is usually below 90 mmHg. Art., pulse - below 20 mm Hg. Art. There are symptoms of deterioration in peripheral circulation (pale cyanotic moist skin, collapsed peripheral veins, decreased skin temperature of the hands and feet); a decrease in blood flow speed (the time it takes for the white spot to disappear after pressing on the nail bed or palm is more than 2 s), a decrease in diuresis (less than 20 ml/h), impaired consciousness (from mildly inhibited to the appearance of focal neurological symptoms and the development of coma).

Differential diagnosis. In most cases, true cardiogenic shock should be differentiated from its other varieties (reflex, arrhythmic, drug, with slow myocardial rupture, rupture of the septum or papillary muscles, damage to the right ventricle), as well as from pulmonary embolism, hypovolemia, internal bleeding and arterial hypotension without shock.

Urgent Care

Emergency care must be carried out in stages, quickly moving to the next stage if the previous one is ineffective.

1. In the absence of pronounced congestion in the lungs:

Place the patient with the lower limbs elevated at an angle of 20° (in case of severe congestion in the lungs - see “Pulmonary edema”):

Carry out oxygen therapy;

In case of anginal pain, carry out complete anesthesia:

Correct heart rate (paroxysmal tachyarrhythmia with heart rate more than 150 beats per minute - absolute reading to EIT, acute bradycardia with heart rate less than 50 beats per 1 min - to pacemaker);

Administer heparin 5000 units intravenously.

2. In the absence of pronounced congestion in the lungs and signs of a sharp increase in central venous pressure:

Inject 200 ml of 0.9% sodium chloride solution intravenously over 10 minutes under the control of blood pressure and respiratory rate. Heart rate, auscultatory picture of the lungs and heart (if possible, control central venous pressure or wedge pressure in the pulmonary artery);

If arterial hypotension persists and there are no signs of transfusion hypervolemia, repeat fluid administration according to the same criteria;

In the absence of signs of transfusion hypervolemia (central venous pressure below 15 cm of water column), continue infusion therapy at a rate of up to 500 ml/h, monitoring these indicators every 15 minutes.

If blood pressure cannot be quickly stabilized, then proceed to the next stage.

3. Introduce dopamine 200 mg in 400 ml of 5% glucose solution intravenously, increasing the infusion rate starting from 5 mcg/(kg x min) until the minimum sufficient blood pressure is achieved;

There is no effect - additionally prescribe norepinephrine hydrotartrate 4 mg in 200 ml of 5% glucose solution intravenously, increasing the infusion rate from 0.5 mcg/min until the minimum sufficient blood pressure is achieved.

4. Monitor vital functions: cardiac monitor, pulse oximeter.

5. Hospitalize after possible stabilization of the condition.

Main dangers and complications:

Delayed diagnosis and initiation of treatment:

Inability to stabilize blood pressure:

Pulmonary edema due to increased blood pressure or intravenous fluid administration;

Tachycardia, tachyarrhythmia, ventricular fibrillation;

Asystole:

Recurrence of anginal pain:

Acute renal failure.

Note. The minimum sufficient blood pressure should be understood as a systolic pressure of about 90 mmHg. Art. when signs of improved perfusion of organs and tissues appear.

Glucocorticoid hormones are not indicated for true cardiogenic shock.

emergency angina heart attack poisoning

HYPERTENSIVE CRISES

Diagnostics. Increased blood pressure (usually acute and significant) with neurological symptoms: headache, “floaters” or blurred vision, paresthesia, “crawling” sensation, nausea, vomiting, weakness in the limbs, transient hemiparesis, aphasia, diplopia.

In neurovegetative crisis (type I crisis, adrenal): sudden onset. excitement, hyperemia and moisture of the skin. tachycardia, frequent and profuse urination, a predominant increase in systolic pressure with an increase in pulse pressure.

In the water-salt form of crisis (type II crisis, norepinephrine): gradual onset, drowsiness, adynamia, disorientation, pallor and puffiness of the face, swelling, a predominant increase in diastolic pressure with a decrease in pulse pressure.

In the convulsive form of the crisis: throbbing, bursting headache, psychomotor agitation, repeated vomiting without relief, visual disturbances, loss of consciousness, clonic-tonic convulsions.

Differential diagnosis. First of all, one should take into account the severity, form and complications of the crisis, identify crises associated with the sudden withdrawal of antihypertensive drugs (clonidine, beta-blockers, etc.), differentiate hypertensive crises from cerebrovascular accidents, diencephalic crises and crises with pheochromocytoma.

Urgent Care

1. Neurovegetative form of crisis.

1.1. For mild cases:

Nifedipine 10 mg sublingually or in drops orally every 30 minutes, or clonidine 0.15 mg sublingually. then 0.075 mg every 30 minutes until effect, or a combination of these drugs.

1.2. In severe cases.

Clonidine 0.1 mg intravenously slowly (can be combined with nifedipine 10 mg sublingually), or sodium nitroprusside 30 mg in 300 ml of 5% glucose solution intravenously, gradually increasing the rate of administration until the required blood pressure is achieved, or pentamin up to 50 mg intravenously drip or stream fractionally;

If the effect is insufficient, furosemide 40 mg intravenously.

1.3. If emotional tension persists, additionally diazepam 5-10 mg orally, intramuscularly or intravenously, or droperidol 2.5-5 mg intravenously slowly.

1.4. For persistent tachycardia, propranolol 20-40 mg orally.

2. Water-salt form of crisis.

2.1. For mild cases:

Furosemide 40-80 mg orally once and nifedipine 10 mg sublingually or in drops orally every 30 minutes until effect, or furosemide 20 mg orally once and captopril sublingually or orally 25 mg every 30-60 minutes until effect.

2.2. In severe cases.

Furosemide 20-40 mg intravenously;

Sodium nitroprusside or pentamine intravenously (section 1.2).

2.3. If neurological symptoms persist, it may be effective intravenous administration 240 mg aminophylline.

3. Convulsive form of crisis:

Diazepam 10-20 mg intravenously slowly until seizures are eliminated; in addition, magnesium sulfate 2.5 g intravenously very slowly can be prescribed:

Sodium nitroprusside (clause 1.2) or pentamine (clause 1.2);

Furosemide 40-80 mg intravenously slowly.

4. Crises associated with sudden withdrawal of antihypertensive drugs:

Appropriate antihypertensive drug intravenously. under the tongue or orally, with severe arterial hypertension - sodium nitroprusside (section 1.2).

5. Hypertensive crisis complicated by pulmonary edema:

Nitroglycerin (preferably aerosol) 0.4-0.5 mg sublingually and immediately 10 mg in 100 ml of isotonic sodium chloride solution intravenously. increasing the rate of administration from 25 mcg/min until the effect is obtained, either sodium nitroprusside (section 1.2) or pentamine (section 1.2);

Furosemide 40-80 mg intravenously slowly;

Oxygen therapy.

6. Hypertensive crisis complicated by hemorrhagic stroke or subarachnoid hemorrhage:

For severe arterial hypertension - sodium nitroprusside (section 1.2). reduce blood pressure to values ​​higher than normal for a given patient; if neurological symptoms increase, reduce the rate of administration.

7. Hypertensive crisis complicated by anginal pain:

Nitroglycerin (preferably an aerosol) 0.4-0.5 mg sublingually and immediately 10 mg intravenously (item 5);

Pain relief is required - see “Angina”:

If the effect is insufficient, propranolol 20-40 mg orally.

8. In case of complicated course- monitor vital functions (cardiac monitor, pulse oximeter).

9. Hospitalize after possible stabilization of the condition .

Main dangers and complications:

Arterial hypotension;

Cerebrovascular accident (hemorrhagic or ischemic stroke);

Pulmonary edema;

Anginal pain, myocardial infarction;

Tachycardia.

Note. In case of acute arterial hypertension, which has not been restored to normal life, reduce blood pressure within 20-30 minutes to the usual, “working” or slightly higher values, use intravenous. route of administration of drugs whose hypotensive effect can be controlled (sodium nitroprusside, nitroglycerin).

In case of a hypertensive crisis without an immediate threat to life, reduce blood pressure gradually (over 1-2 hours).

If the course of hypertension worsens, not reaching a crisis, blood pressure must be reduced within several hours, and the main antihypertensive drugs should be prescribed orally.

In all cases, blood pressure should be reduced to the usual, “working” values.

Provide emergency care for repeated hypertensive crises of sls diets, taking into account the existing experience in treating previous ones.

When using captopril for the first time, treatment should begin with a trial dose of 6.25 mg.

The hypotensive effect of pentamine is difficult to control, so the drug can only be used in cases where an emergency reduction in blood pressure is indicated and there are no other possibilities for this. Pentamine is administered 12.5 mg intravenously in fractional doses or drops up to 50 mg.

During a crisis in patients with pheochromocytoma, raise the head of the bed. 45°; prescribe (rentolation (5 mg intravenously after 5 minutes until effect); you can use prazosin 1 mg sublingually repeatedly or sodium nitroprusside. As an auxiliary drug - droperidol 2.5-5 mg intravenously slowly. Change P-adrenergic receptor blockers only (!) after the introduction of α-adrenoreceptor blockers.

PULMONARY EMBOLISM

Diagnostics Massive pulmonary embolism appears sudden stop blood circulation electromechanical dissociation), or shock with severe shortness of breath, tachycardia, pallor or severe cyanosis of the skin of the upper half of the body, swelling of the neck veins, antinoxious pain, electrocardiographic manifestations of acute “pulmonary heart”.

Non-passive pulmonary embolism is manifested by shortness of breath, tachycardia, and arterial hypotension. signs of pulmonary infarction (pulmonary-pleural pain, cough, in some patients - with sputum stained with blood, increased body temperature, crepitating rales in the lungs).

To diagnose PE, it is important to take into account the presence of such risk factors for the development of thromboembolism, such as a history of thromboembolic complications, old age, prolonged mobilization, recent surgical intervention, heart disease, heart failure, atrial fibrillation, oncological diseases, DVT.

Differential diagnosis. In most cases - with myocardial infarction, acute heart failure (cardiac asthma, pulmonary edema, cardiogenic shock), bronchial asthma, pneumonia, spontaneous pneumothorax.

Urgent Care

1. If blood circulation stops - CPR.

2. In case of massive pulmonary embolism with arterial hypotension:

Oxygen therapy:

Catheterization of the central or peripheral vein:

Heparin 10,000 units intravenously in a bolus, then drip at an initial rate of 1000 units/hour:

Infusion therapy (reopolyglucin, 5% glucose solution, hemodez, etc.).

3. In case of severe arterial hypotension not corrected by infusion therapy:

Dopamine, or adrenaline, intravenous drip. increasing the rate of administration until blood pressure stabilizes;

Streptokinase (250,000 IU intravenous drip over 30 minutes, then intravenous drip at a rate of 100,000 IU/hour to a total dose of 1,500,000 IU).

4. With stable blood pressure:

Oxygen therapy;

Peripheral vein catheterization;

Heparin 10,000 units intravenously as a bolus, then drip at a rate of 1000 units/hour or subcutaneously at 5000 units after 8 hours:

Eufillin 240 mg intravenously.

5. In case of recurrent pulmonary embolism, additionally prescribe 0.25 g of acetylsalicylic acid orally.

6. Monitor vital functions (cardiac monitor, pulse oximeter).

7. Hospitalize after possible stabilization of the condition.

Main dangers and complications:

Electromechanical dissociation:

Inability to stabilize blood pressure;

Increasing respiratory failure:

Recurrence of pulmonary embolism.

Note. In case of a burdened allergic history, 30 mg of predniolone is injected intravenously before prescribing sprepyukinosis.

For the treatment of pulmonary embolism, the rate of intravenous heparin administration must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared to its normal value.

STROKE (ACUTE CEREBRAL CIRCULATION DISORDER)

Stroke (stroke) is a rapidly developing focal or global disorder of brain function that lasts more than 24 hours or leads to death if another genesis of the disease is excluded. Develops against the background of atherosclerosis of cerebral vessels, hypertension, their combination, or as a result of rupture of cerebral aneurysms.

Diagnostics The clinical picture depends on the nature of the process (ischemia or hemorrhage), localization (hemispheres, brainstem, cerebellum), rate of development of the process (sudden, gradual). A stroke of any origin is characterized by the presence focal symptoms brain lesions (hemiparesis or hemiplegia, less commonly monoparesis and lesions cranial nerves- facial, sublingual, oculomotor) and general cerebral symptoms varying degrees severity (headache, dizziness, nausea, vomiting, impaired consciousness).

ACVA is clinically manifested by subarachnoid or intracerebral hemorrhage (hemorrhagic stroke), or ischemic stroke.

Transient cerebrovascular accident (TCI) is a condition in which focal symptoms undergo complete regression in a period of less than 24 hours. The diagnosis is made retrospectively.

Suborocnoidal hemorrhages develop as a result of rupture of aneurysms and, less often, against the background of hypertension. Characterized by the sudden onset of a sharp headache, followed by nausea, vomiting, motor agitation, tachycardia, and sweating. With massive subarachnoid hemorrhage, depression of consciousness is usually observed. Focal symptoms are often absent.

Hemorrhagic stroke - hemorrhage into the substance of the brain; characterized by a sharp headache, vomiting, rapid (or sudden) depression of consciousness, accompanied by the appearance of severe symptoms of impaired function of the limbs or bulbar disorders (peripheral paralysis of the muscles of the tongue, lips, soft palate, pharynx, vocal folds and epiglottis due to damage to the IX, X and XII pairs of cranial nerves or their nuclei located in the medulla oblongata). It usually develops during the day, while awake.

Ischemic stroke is a disease that leads to a decrease or cessation of blood supply to a certain part of the brain. It is characterized by a gradual (over hours or minutes) increase in focal symptoms corresponding to the affected vascular system. General cerebral symptoms are usually less pronounced. Develops more often with normal or low blood pressure, often during sleep

At the prehospital stage, differentiation of the nature of the stroke (ischemic or hemorrhagic, subarachnoid hemorrhage and its location is not required.

Differential diagnosis should be carried out with traumatic brain injury (history, presence of traces of trauma on the head) and much less often with meningoencephalitis (history, signs of a general infectious process, rash).

Urgent Care

Basic (undifferentiated) therapy includes emergency correction of vital functions - restoration of patency of the upper respiratory tract, if necessary - tracheal intubation, artificial ventilation, as well as normalization of hemodynamics and cardiac activity:

If blood pressure is significantly higher than normal values ​​- reduce it to levels slightly higher than the “working” one, usual for a given patient; if there is no information, then to a level of 180/90 mm Hg. Art.; for this use - 0.5-1 ml of a 0.01% solution of clonidine (clonidine) in 10 ml of a 0.9% solution of sodium chloride intravenously or intramuscularly or 1-2 tablets sublingually (if necessary, the administration of the drug can be repeated), or pentamin - no more than 0. 5 ml of a 5% solution intravenously at the same dilution or 0.5-1 ml intramuscularly:

As an additional remedy, you can use dibazol 5-8 ml of 1% solution intravenously or nifedipine (Corinfar, phenigidine) - 1 tablet (10 mg) sublingually;

For cupping seizures, psychomotor agitation - diazepam (Relanium, Seduxen, Sibazon) 2-4 ml intravenously with 10 ml of 0.9% sodium chloride solution slowly or intramuscularly or Rohypnol 1-2 ml intramuscularly;

If ineffective - 20% sodium hydroxybutyrate solution at the rate of 70 mg/kg body weight in a 5-10% glucose solution, slowly intravenously;

In case of repeated vomiting - Cerucal (Raglan) 2 ml intravenously in a 0.9% solution intravenously or intramuscularly:

Vitamin Wb 2 ml of 5% solution intravenously;

Droperidol 1-3 ml of 0.025% solution, taking into account the patient’s body weight;

For headaches - 2 ml of 50% analgin solution or 5 ml of baralgin intravenously or intramuscularly;

Tramal - 2 ml.

Tactics

For patients of working age, in the first hours of the disease it is mandatory to call a specialized neurological (neuro-resuscitation) team. Hospitalization on a stretcher to the neurological (neurovascular) department is indicated.

If you refuse hospitalization, call a neurologist at the clinic and, if necessary, actively visit an emergency doctor after 3-4 hours.

Patients in deep atonic coma (5-4 points on the Glasgow scale) with intractable severe breathing disorders: unstable hemodynamics, with a rapid, steady deterioration of their condition are not transportable.

Dangers and complications

Obstruction of the upper respiratory tract by vomit;

Aspiration of vomit;

Inability to normalize blood pressure:

Brain swelling;

A breakthrough of blood into the ventricles of the brain.

Note

1. Early use of antihypoxants and activators of cellular metabolism is possible (nootropil 60 ml (12 g) intravenously 2 times a day after 12 hours on the first day; Cerebrolysin 15-50 ml intravenous drip per 100-300 ml isotonic solution in 2 doses; glycine 1 tablet under the tongue ribojusin 10 ml intravenous bolus, solcoseryl 4 ml intravenous bolus, in severe cases 250 ml of 10% solution of solcoseryl intravenous drip can significantly reduce the number of irreversibly damaged cells in the ischemic zone, reduce the area of ​​perifocal edema.

2. Aminazine and propazine should be excluded from drugs prescribed for any form of stroke. These drugs sharply inhibit the functions of brain stem structures and clearly worsen the condition of patients, especially the elderly and senile.

3. Magnesium sulfate is not used for seizures and to lower blood pressure.

4. Eufillin is shown only in the first hours of a mild stroke.

5. Furosemide (Lasix) and other dehydrating drugs (mannitol, reogluman, glycerol) should not be administered at the prehospital stage. The need to prescribe dehydrating agents can only be determined in a hospital based on the results of determining plasma osmolality and sodium content in blood serum.

6. In the absence of a specialized neurological team, hospitalization in the neurological department is indicated.

7. For patients of any age with a first or repeated stroke with minor defects after previous episodes, a specialized neurological (neuro-resuscitation) team can also be called on the first day of the disease.

BRONCHASTMATIC STATUS

Bronchoasthmic status is one of the most severe variants of the course of bronchial asthma, manifested by acute obstruction bronchial tree as a result of bronchiolospasm, hyperergic inflammation and swelling of the mucous membrane, hypersecretion of the glandular apparatus. The formation of the status is based on a deep blockade of beta-adrenergic receptors of the smooth muscles of the bronchi.

Diagnostics

An attack of suffocation with difficulty exhaling, increasing shortness of breath at rest, acrocyanosis, increased sweating, harsh breathing with dry scattered wheezing and subsequent formation of areas of “silent” lung, tachycardia, high blood pressure, participation of auxiliary muscles in breathing, hypoxic and hypercapnic coma. During drug therapy, resistance to sympathomimetics and other bronchodilators is revealed.

Urgent Care

Status asthmaticus is a contraindication to the use of β-agonists (adrenergic agonists) due to loss of sensitivity (lung receptors to these drugs. However, this loss of sensitivity can be overcome using nebulizer technology.

Drug therapy is based on the use of selective β2-agonists fenoterol (Beroteca) at a dose of 0.5-1.5 mg or salbutamol at a dose of 2.5-5.0 mg, or a complex drug Berodual containing fenoterol and the anticholinergic drug ipra, using the nebulizer technique -tropium bromide (Atrovent). Berodual dosage is 1-4 ml per inhalation.

In the absence of a nebulizer, these drugs are not used.

Eufillin is used in the absence of a nebulizer or in particularly severe cases when nebulizer therapy is ineffective.

Initial dose - 5.6 mg/kg body weight (10-15 ml of 2.4% solution intravenously slowly, over 5-7 minutes);

Maintenance dose - 2-3.5 ml of a 2.4% solution in fractions or drops until the patient’s clinical condition improves.

Glucocorticoid hormones - in terms of methylprednisolone 120-180 mg intravenously.

Oxygen therapy. Continuous insufflation (mask, nasal catheters) of an oxygen-air mixture with an oxygen content of 40-50%.

Heparin - 5,000-10,000 units intravenously drip with one of the plasma-substituting solutions; it is possible to use low molecular weight heparins (fraxiparine, clexane, etc.)

Contraindicated

Sedatives and antihistamines (inhibit the cough reflex, increase bronchopulmonary obstruction);

Mucolytic agents for thinning sputum:

antibiotics, sulfonamides, novocaine (have high sensitizing activity);

Calcium supplements (deepen initial hypokalemia);

Diuretics (increase initial dehydration and hemoconcentration).

In a comatose state

Urgent tracheal intubation with spontaneous breathing:

Artificial ventilation;

If necessary, perform cardiopulmonary resuscitation;

Drug therapy (see above)

Indications for tracheal intubation and mechanical ventilation:

hypoxic and hyperkalemic coma:

Cardiovascular collapse:

The number of respiratory movements is more than 50 per 1 minute. Transportation to the hospital during therapy.

CONVIVUS SYNDROME

Diagnostics

A generalized generalized convulsive seizure is characterized by the presence of tonic-clonic convulsions in the extremities, accompanied by loss of consciousness, foam at the mouth, often tongue biting, involuntary urination, and sometimes defecation. At the end of the attack, a pronounced respiratory arrhythmia is observed. Long periods of apnea are possible. At the end of the seizure, the patient is in a deep coma, the pupils are maximally dilated, without reaction to light, the skin is cyanotic, often moist.

Simple partial seizures without loss of consciousness are manifested by clonic or tonic convulsions in certain muscle groups.

Complex partial seizures (temporal lobe epilepsy or psychomotor seizures) are episodic changes in behavior when the patient loses contact with the outside world. The beginning of such seizures can be an aura (olfactory, gustatory, visual, a feeling of “already seen,” micro- or macropsia). During complex attacks, inhibition of motor activity may be observed; or smacking tubes, swallowing, walking aimlessly, picking off one’s own clothes (automatisms). At the end of the attack, amnesia is noted for the events that took place during the attack.

The equivalents of convulsive seizures manifest themselves in the form of gross disorientation, somnambulism and a prolonged twilight state, during which unconscious, severe asocial acts can be committed.

Status epilepticus is a fixed epileptic state due to a prolonged epileptic seizure or a series of seizures repeated at short intervals. Status epilepticus and frequent seizures are life-threatening conditions.

A seizure can be a manifestation of genuine (“congenital”) and symptomatic epilepsy - a consequence of previous diseases (brain trauma, cerebrovascular accident, neuroinfection, tumor, tuberculosis, syphilis, toxoplasmosis, cysticercosis, Morgagni-Adams-Stokes syndrome, ventricular fibrillation , eclampsia) and intoxication.

Differential diagnosis

At the prehospital stage, determining the cause of a seizure is often extremely difficult. Anamnesis and clinical data are of great importance. Particular caution must be exercised in relation to primarily, traumatic brain injury, acute cerebrovascular accidents, heart rhythm disturbances, eclampsia, tetanus and exogenous intoxications.

Urgent Care

1. After a single convulsive seizure - diazepam (Relanium, Seduxen, Sibazon) - 2 ml intramuscularly (as a prevention of repeated seizures).

2. With a series of convulsive seizures:

Prevention of head and torso injuries:

Relief of convulsive syndrome: diazepam (Relanium, Seduxen, Sibazon) - 2-4 ml per 10 ml of 0.9% sodium chloride solution intravenously or intramuscularly, Rohypnol 1-2 ml intramuscularly;

If there is no effect, sodium hydroxybutyrate 20% solution at the rate of 70 mg/kg body weight intravenously in a 5-10% glucose solution;

Decongestant therapy: furosemide (Lasix) 40 mg per 10-20 ml of 40% glucose or 0.9% sodium chloride solution (in patients diabetes mellitus)

intravenously;

Relief of headaches: analgin 2 ml of 50% solution: baralgin 5 ml; Tramal 2 ml intravenously or intramuscularly.

3. Status epilepticus

Prevention of head and torso injuries;

Restoration of airway patency;

Relief of convulsive syndrome: diazepam (Relanium, Seduxen, Syabazon) _ 2-4 ml per 10 ml of 0.9% sodium chloride solution intravenously or intramuscularly, Rohypnol 1-2 ml intramuscularly;

If there is no effect, sodium hydroxybutyrate 20% solution at the rate of 70 mg/kg body weight intravenously in a 5-10% glucose solution;

If there is no effect, inhalation anesthesia with nitrous oxide mixed with oxygen (2:1).

Decongestant therapy: furosemide (Lasix) 40 mg per 10-20 ml of 40% glucose or 0.9% sodium chloride solution (in patients with diabetes) intravenously:

Headache relief:

Analgin - 2 ml of 50% solution;

- baralgin - 5 ml;

Tramal - 2 ml intravenously or intramuscularly.

According to indications:

If blood pressure increases significantly above the patient’s usual levels, use antihypertensive drugs (clonidine intravenously, intramuscularly or sublingually tablets, dibazol intravenously or intramuscularly);

For tachycardia over 100 beats/min - see “Tachyarrhythmias”:

For bradycardia less than 60 beats/min - atropine;

For hyperthermia above 38° C - analgin.

Tactics

Patients with their first seizure in their life should be hospitalized to determine its cause. In case of refusal of hospitalization with a rapid recovery of consciousness and the absence of general cerebral and focal neurological symptoms, it is recommended to urgently contact a neurologist at a local clinic. If consciousness is restored slowly, there are general cerebral and (or) focal symptoms, then a call to a specialized neurological (neuro-resuscitation) team is indicated, and in its absence, an active visit after 2-5 hours.

Intractable status epilepticus or a series of convulsive seizures is an indication to call a specialized neurological (neuro-resuscitation) team. If this is not the case, hospitalization is required.

If there is a disturbance in the activity of the heart, leading to a convulsive syndrome, appropriate therapy or calling a specialized cardiology team. In case of eclampsia, exogenous intoxication - action according to the relevant recommendations.

Main dangers and complications

Asphyxia during a seizure:

Development of acute heart failure.

Note

1. Aminazine is not an anticonvulsant.

2. Magnesium sulfate and chloral hydrate are not currently used.

3. The use of hexenal or sodium thiopental to relieve status epilepticus is possible only in the conditions of a specialized team, if conditions are available and the ability to transfer the patient to mechanical ventilation if necessary. (laryngoscope, set of endotracheal tubes, ventilator).

4. For glucalcemic convulsions, calcium gluconate (10-20 ml of a 10% solution intravenously or intramuscularly), calcium chloride (10-20 ml of a 10% solution strictly intravenously) are administered.

5. For hypokalemic convulsions, administer panangin (10 ml intravenously).

FAINTING (BRIEF LOSS OF CONSCIOUSNESS, SYNCOPE)

Diagnostics

Fainting. - short-term (usually within 10-30 s) loss of consciousness. in most cases accompanied by a decrease in postural vascular tone. Fainting is based on transient hypoxia of the brain, which occurs due to various reasons - a decrease in cardiac output. heart rhythm disturbances, reflex decrease in vascular tone, etc.

Fainting (syncope) conditions can be conditionally divided into two most common forms - vasodepressor (synonyms - vasovagal, neurogenic) fainting, which is based on a reflex decrease in postural vascular tone, and fainting associated with diseases of the heart and great vessels.

Syncope conditions have different prognostic significance depending on their genesis. Fainting associated with pathology of the cardiovascular system can be a harbinger of sudden death and requires mandatory identification of their causes and adequate treatment. It must be remembered that fainting can be the onset of a serious pathology (myocardial infarction, pulmonary embolism, etc.).

The most common clinical form is vasodepressor syncope, in which a reflex decrease in peripheral vascular tone occurs in response to external or psychogenic factors (fear, anxiety, the sight of blood, medical instruments, venous puncture. heat environment, staying in a stuffy room, etc.). The development of fainting is preceded by a short prodromal period, during which weakness, nausea, ringing in the ears, yawning, darkening of the eyes, pallor, and cold sweat are noted.

If the loss of consciousness is short-term, there are no seizures. If fainting lasts more than 15-20 seconds. clonic and tonic convulsions are observed. During fainting, there is a decrease in blood pressure with bradycardia; or without it. This group also includes fainting that occurs with increased sensitivity of the carotid sinus, as well as so-called “situational” fainting - with prolonged coughing, defecation, and urination. Syncope associated with pathology of cardio-vascular system, usually occur suddenly, without a prodromal period. They are divided into two main groups - those associated with disturbances of heart rhythm and conduction and those caused by a decrease in cardiac output (aortic stenosis, hypertrophic cardiomyopathy, myxoma and spherical thrombi in the atria, myocardial infarction, pulmonary embolism, dissecting aortic aneurysm).

Differential diagnosis fainting should be carried out with epilepsy, hypoglycemia, narcolepsy, comas of various origins, diseases of the vestibular apparatus, organic pathology of the brain, hysteria.

In most cases, diagnosis can be made based on a detailed history, physical examination, and ECG recording. To confirm the vasodepressor nature of fainting, positional tests are performed (from simple orthostatic tests to the use of a special inclined table); to increase sensitivity, tests are carried out against the background of drug therapy. If these actions do not clarify the cause of fainting, then a subsequent examination in a hospital is carried out depending on the identified pathology.

In the presence of heart disease: Holter ECG monitoring, echocardiography, electrophysiological study, positional tests: if necessary, cardiac catheterization.

In the absence of heart disease: positional tests, consultation with a neurologist, psychiatrist, Holter ECG monitoring, electroencephalogram, if necessary - CT scan brain, angiography.

Urgent Care

In case of fainting it is usually not required.

The patient must be placed in a horizontal position on his back:

give lower limbs elevated position, free your neck and chest from constricting clothing:

Patients should not be seated immediately, as this may lead to recurrence of fainting;

If the patient does not regain consciousness, it is necessary to exclude traumatic brain injury (if there was a fall) or other causes of prolonged loss of consciousness mentioned above.

If syncope is caused by a cardiac disease, emergency care may be necessary to eliminate the immediate cause of syncope - tachyarrhythmia, bradycardia, hypotension, etc. (see relevant sections).

ACUTE POISONING

Poisoning is a pathological condition caused by the action of toxic substances of exogenous origin through any route of entry into the body.

The severity of the poisoning condition is determined by the dose of the poison, the route of its intake, the exposure time, the patient’s premorbid background, complications (hypoxia, bleeding, convulsions, acute cardiovascular failure, etc.).

The prehospital doctor needs to:

Observe “toxicological alertness” (the environmental conditions in which the poisoning occurred, the presence of foreign odors may pose a danger to the ambulance team):

Find out the circumstances surrounding the poisoning (when, with what, how, how much, for what purpose) in the patient himself, if he is conscious, or in those around him;

Collect material evidence (packages of medicines, powders, syringes), biological media (vomit, urine, blood, washing water) for chemical-toxicological or forensic chemical research;

Register the main symptoms (syndromes) that the patient had before providing medical care, including mediator syndromes that are the result of strengthening or suppression of the sympathetic and parasympathetic systems (see appendix).

GENERAL ALGORITHM FOR PROVIDING EMERGENCY CARE

1. Ensure normalization of breathing and hemodynamics (perform basic cardiopulmonary resuscitation).

2. Carry out antidote therapy.

3. Stop further entry of poison into the body. 3.1. In case of inhalation poisoning, remove the victim from the contaminated atmosphere.

3.2. In case of oral poisoning, rinse the stomach, administer enteric sorbents, and give a cleansing enema. When washing the stomach or washing off poisons from the skin, use water with a temperature no higher than 18 ° C; do not carry out a reaction to neutralize the poison in the stomach! The presence of blood during gastric lavage is not a contraindication for lavage.

3.3. For cutaneous application, wash the affected area of ​​skin with an antidote solution or water.

4. Start infusion and symptomatic therapy.

5. Transport the patient to the hospital. This algorithm for providing care at the prehospital stage is applicable to all types of acute poisoning.

Diagnostics

With mild to moderate severity, anticholinergic syndrome occurs (intoxication psychosis, tachycardia, normohypotension, mydriasis). In severe cases, coma, hypotension, tachycardia, mydriasis.

Neuroleptics cause the development of orthostatic collapse, long-term persistent hypotension due to the insensitivity of the terminal vascular bed to vasopressors, extrapyramidal syndrome (muscle spasms of the chest, neck, upper shoulder girdle, protrusion of the tongue, bulging eyes), neuroleptic syndrome (hyperthermia, muscle rigidity).

Hospitalization of the patient in a horizontal position. Anticholinergics cause the development of retrograde amnesia.

Opiate poisoning

Diagnostics

Characteristic: depression of consciousness, to deep coma. development of apnea, tendency to bradycardia, injection marks on the elbows.

Emergency treatment

Pharmacological antidotes: naloxone (Narkanti) 2-4 ml of 0.5% solution intravenously until spontaneous breathing is restored: if necessary, repeat administration until mydriasis appears.

Start infusion therapy:

400.0 ml of 5-10% glucose solution intravenously;

Reopoliglucin 400.0 ml intravenous drip.

Sodium bicarbonate 300.0 ml 4% intravenous drip;

Oxygen inhalation;

If there is no effect from the administration of naloxone, perform mechanical ventilation in hyperventilation mode.

Tranquilizer poisoning (benzodiazepine group)

Diagnostics

Characteristics: drowsiness, ataxia, depression of consciousness to the point of coma 1, miosis (in case of Noxiron poisoning - mydriasis) and moderate hypotension.

Benzodiazepine tranquilizers cause deep depression of consciousness only in “mixed” poisonings, i.e. in combination with barbiturates. neuroleptics and other sedative-hypnotics.

Emergency treatment

Follow steps 1-4 of the general algorithm.

For hypotension: rheopolyglucin 400.0 ml intravenously, drip:

Barbiturate poisoning

Diagnostics

Miosis, hypersalivation, “greasy” skin, hypotension, deep depression of consciousness up to the development of coma are detected. Barbiturates cause a rapid breakdown of tissue trophism, the formation of bedsores, the development of positional compression syndrome, and pneumonia.

Urgent Care

Pharmacological antidotes (see note).

Execute point 3 of the general algorithm;

Start infusion therapy:

Sodium bicarbonate 4% 300.0, intravenous drip:

Glucose 5-10% 400.0 ml intravenous drip;

Sulphocamphocaine 2.0 ml intravenously.

Oxygen inhalation.

POISONING WITH STIMULATING DRUGS

These include antidepressants, psychostimulants, general tonics (tinctures, including alcoholic ginseng, eleutherococcus).

Delirium, hypertension, tachycardia, mydriasis, convulsions, cardiac arrhythmias, ischemia and myocardial infarction are determined. They cause depression of consciousness, hemodynamics and respiration after the phase of excitation and hypertension.

Poisoning occurs with adrenergic (see appendix) syndrome.

Antidepressant poisoning

Diagnostics

With a short duration of action (up to 4-6 hours), hypertension is determined. delirium. dry skin and mucous membranes, expansion of the 9K8 complex on the ECG (quinidine-like effect of tricyclic antidepressants), convulsive syndrome.

With prolonged action (more than 24 hours) - hypotension. urinary retention, coma. Always - mydriasis. dry skin, expansion of the OK8 complex on the ECG: Antidepressants. serotonin blockers: fluoxentine (Prozac), fluvoxamine (paroxetine), alone or in combination with analgesics, can cause “malignant” hyperthermia.

Urgent Care

Execute point 1 of the general algorithm. For hypertension and agitation:

Short-acting drugs with a rapid onset of effect: galantamine hydrobromide (or nivalin) 0.5% - 4.0-8.0 ml, intravenously;

Long-acting drugs: aminostigmine 0.1% - 1.0-2.0 ml intramuscularly;

In the absence of antagonists, anticonvulsants: Relanium (Seduxen), 20 mg per 20.0 ml of 40% glucose solution intravenously; or sodium hydroxybutyrate 2.0 g per - 20.0 ml of 40.0% glucose solution intravenously, slowly);

Follow step 3 of the general algorithm. Start infusion therapy:

In the absence of sodium bicarbonate - trisol (disol. hlosol) 500.0 ml intravenously, drip.

With severe arterial hypotension:

Reopoliglucin 400.0 ml intravenously, drip;

Norepinephrine 0.2% 1.0 ml (2.0) in 400 ml of 5-10% glucose solution intravenously, drip, increase the rate of administration until blood pressure stabilizes.

POISONING BY ANTI-TUBERCULOSIS DRUGS (INSONIAZIDE, FTIVAZIDE, TUBAZIDE)

Diagnostics

Characteristic: generalized convulsive syndrome, development of stunning. up to coma, metabolic acidosis. Any convulsive syndrome resistant to treatment with benzodiazepines should alert you to isoniazid poisoning.

Urgent Care

Execute point 1 of the general algorithm;

For convulsive syndrome: pyridoxine up to 10 ampoules (5 g). intravenous drip of 400 ml of 0.9% sodium chloride solution; Relanium 2.0 ml, intravenously. until the convulsive syndrome is relieved.

If there is no result, anti-depolarizing muscle relaxants (Arduan 4 mg), tracheal intubation, mechanical ventilation.

Follow step 3 of the general algorithm.

Start infusion therapy:

Sodium bicarbonate 4% 300.0 ml intravenously, drip;

Glucose 5-10% 400.0 ml intravenously, drip. For arterial hypotension: rheopolyglucin 400.0 ml intravenously. drip.

Early detoxification hemosorption is effective.

POISONING BY TOXIC ALCOHOLS (METHANOL, ETHYLENE GLYCOL, CELLOSOLV)

Diagnostics

Characteristic: the effect of intoxication, decreased visual acuity (methanol), abdominal pain (propyl alcohol; ethylene glycol, cellosolve with prolonged exposure), depression of consciousness to deep coma, decompensated metabolic acidosis.

Urgent Care

Follow step 1 of the general algorithm:

Follow step 3 of the general algorithm:

The pharmacological antidote for methanol, ethylene glycol and cellosolves is ethanol.

Initial therapy with ethanol (saturation dose per 80 kg of patient’s body weight, at the rate of 1 ml of 96% alcohol solution per 1 kg of body weight). To do this, dilute 80 ml of 96% alcohol with water and give it to drink (or administer it through a tube). If it is impossible to prescribe alcohol, 20 ml of a 96% alcohol solution is dissolved in 400 ml of a 5% glucose solution and the resulting alcoholic glucose solution is injected into a vein at a rate of 100 drops/min (or 5 ml of solution per min).

Start infusion therapy:

Sodium bicarbonate 4% 300 (400) intravenously, drip;

Acesol 400 ml intravenously, drip:

Hemodez 400 ml intravenously, drip.

When transferring the patient to the hospital, indicate the dose, time and route of administration of the ethanol solution at the prehospital stage to provide a maintenance dose of ethanol (100 mg/kg/hour).

ETHANOL POISONING

Diagnostics

Determined: depression of consciousness to deep coma, hypotension, hypoglycemia, hypothermia, cardiac arrhythmia, respiratory depression. Hypoglycemia and hypothermia lead to the development of heart rhythm disturbances. In alcoholic coma, lack of response to naloxone may be due to concomitant traumatic brain injury (subdural hematoma).

Urgent Care

Follow steps 1-3 of the general algorithm:

For depression of consciousness: naloxone 2 ml + glucose 40% 20-40 ml + thiamine 2.0 ml intravenously slowly. Start infusion therapy:

Sodium bicarbonate 4% 300-400 ml intravenous drip;

Hemodez 400 ml intravenous drip;

Sodium thiosulfate 20% 10-20 ml intravenously slowly;

Unithiol 5% 10 ml intravenously slowly;

Ascorbic acid 5 ml intravenously;

Glucose 40% 20.0 ml intravenously.

When excited: Relanium 2.0 ml intravenously slowly with 20 ml of 40% glucose solution.

Alcohol-induced withdrawal symptoms

When examining a patient at the prehospital stage, it is advisable to adhere to certain sequences and principles of emergency care for acute alcohol poisoning.

· Establish the fact of recent alcohol intake and determine its characteristics (date of last intake, binge drinking or one-time use, quantity and quality of alcohol consumed, total duration of regular alcohol intake). It is possible to adjust for the social status of the patient.

· Establish the fact of chronic alcohol intoxication and nutritional level.

· Determine the risk of developing withdrawal syndrome.

· Within the framework of toxic visceropathy, determine: the state of consciousness and mental functions, identify gross neurological disorders; stage of alcoholic liver disease, degree of liver failure; identify damage to other target organs and the degree of their functional usefulness.

· Determine the prognosis of the condition and develop a plan for observation and pharmacotherapy.

· Obviously, clarifying the patient’s “alcohol” history is aimed at determining the severity of the current acute alcohol poisoning, as well as the risk of developing alcohol withdrawal syndrome (on the 3-5th day after the last alcohol intake).

When treating acute alcohol intoxication, a set of measures is required, aimed, on the one hand, at stopping further absorption of alcohol and accelerating its elimination from the body, and on the other, at protecting and maintaining systems or functions that suffer from the effects of alcohol.

The intensity of therapy is determined both by the severity of acute alcohol intoxication and the general condition of the intoxicated person. In this case, gastric lavage is performed to remove alcohol that has not yet been absorbed, and drug therapy with detoxification agents and alcohol antagonists.

In the treatment of alcohol withdrawal the doctor takes into account the severity of the main components of the withdrawal syndrome (somato-vegetative, neurological and mental disorders). Mandatory components are vitamin and detoxification therapy.

Vitamin therapy includes parenteral administration of solutions of thiamine (Vit B1) or pyridoxine hydrochloride (Vit B6) - 5-10 ml. For severe tremor, a solution of cyanocobalamin (Vit B12) is prescribed - 2-4 ml. The simultaneous administration of various B vitamins is not recommended due to the possibility of increased allergic reactions and their incompatibility in one syringe. Ascorbic acid (Vit C) - up to 5 ml is administered intravenously along with plasma-substituting solutions.

Detoxification therapy includes the administration of thiol drugs - 5% unithiol solution (1 ml per 10 kg of body weight intramuscularly) or 30% sodium thiosulfate solution (up to 20 ml); hypertonic - 40% glucose - up to 20 ml, 25% magnesium sulfate (up to 20 ml), 10% calcium chloride (up to 10 ml), isotonic - 5% glucose (400-800 ml), 0.9% sodium chloride solution ( 400-800 ml) and plasma-substituting - hemodez (200-400 ml) solutions. It is also advisable to administer intravenously a 20% solution of piracetam (up to 40 ml).

These measures, according to indications, are supplemented by the relief of somato-vegetative, neurological and mental disorders.

If blood pressure increases, 2-4 ml of papaverine hydrochloride or dibazole solution is injected intramuscularly;

In case of heart rhythm disturbances, analeptics are prescribed - a solution of cordiamine (2-4 ml), camphor (up to 2 ml), potassium preparations panangin (up to 10 ml);

In case of shortness of breath, difficulty breathing, up to 10 ml of a 2.5% aminophylline solution is injected intravenously.

A reduction in dyspeptic symptoms is achieved by administering a solution of raglan (cerucal - up to 4 ml), as well as antispasmodics - baralgin (up to 10 ml), NO-ShPy (up to 5 ml). A solution of baralgin, along with a 50% solution of analgin, is also indicated to reduce the severity of headaches.

For chills and sweating, a solution is administered nicotinic acid(Vit PP - up to 2 ml) or 10% calcium chloride solution - up to 10 ml.

Psychotropic drugs are used to relieve affective, psychopathic and neurosis-like disorders. Relanium (dizepam, seduxen, sibazon) is administered intramuscularly or at the end of an intravenous infusion of solutions intravenously in a dose of up to 4 ml for withdrawal states with anxiety, irritability, sleep disorders, and autonomic disorders. Nitrazepam (Eunoctin, Radedorm - up to 20 mg), phenazepam (up to 2 mg), Grandaxin (up to 600 mg) are given orally, but it must be taken into account that nitrazepam and phenazepam are best used to normalize sleep, and Grandaxin to relieve autonomic disorders.

For severe affective disorders (irritability, tendency to dysphoria, outbursts of anger), antipsychotics with a hypnotic-sedative effect are used (droperidol 0.25% - 2-4 ml).

For rudimentary visual or auditory hallucinations, paranoid mood in the structure of abstinence, 2-3 ml of a 0.5% solution of haloperidol is injected intramuscularly in combination with Relanium to reduce neurological side effects.

For severe motor restlessness, use droperidol 2-4 ml of a 0.25% solution intramuscularly or sodium hydroxybutyrate 5-10 ml of a 20% solution intravenously. Neuroleptics from the group of phenothiazines (aminazine, tizercin) and tricyclic antidepressants (amitriptyline) are contraindicated.

Therapeutic measures are carried out until signs of a clear improvement in the patient’s condition appear (reduction of somato-vegetative, neurological, mental disorders, normalization of sleep) under constant monitoring of the function of the cardiovascular or respiratory system.

Electrocardiostimulation

Electrocardiac pacing (PAC) is a method by which external electrical impulses generated by an artificial pacemaker (pacemaker) are applied to any part of the heart muscle, resulting in a contraction of the heart.

Indications for cardiac pacing

· Asystole.

· Severe bradycardia, regardless of the underlying cause.

· Atrioventricular or Sinoatrial block with Adams-Stokes-Morgagni attacks.

There are 2 types of pacing: permanent pacing and temporary pacing.

1. Permanent pacing

Permanent cardiac pacing is the implantation of an artificial pacemaker or cardioverter-defibrillator. Temporary cardiac pacing

2. Temporary cardiac pacing is necessary for severe bradyarrhythmias caused by sinus node dysfunction or AV block.

Temporary pacing may be performed various methods. Transvenous endocardial and transesophageal pacing, as well as in some cases external percutaneous pacing, are relevant today.

Transvenous (endocardial) electrocardiostimulation has received especially intensive development, since it is the only effective way“impose” an artificial rhythm on the heart in the event of severe disturbances of systemic or regional circulation due to bradycardia. When performing it, an electrode under ECG control through the subclavian, internal jugular, ulnar or femoral vein injected into the right atrium or right ventricle.

Temporary transesophageal atrial pacing and transesophageal ventricular pacing (TEV) have also become widespread. CPES is used as replacement therapy with bradycardia, bradyarrhythmia, asystole and sometimes with reciprocal supraventricular arrhythmias. It is often used for diagnostic purposes. Temporary transthoracic pacing is sometimes used by emergency physicians to buy time. One electrode is inserted through a percutaneous puncture into the heart muscle, and the second is a needle installed subcutaneously.

Indications for temporary pacing

· Temporary cardiac pacing is carried out in all cases where there are indications for permanent cardiac pacing as a “bridge” to it.

· Temporary cardiac pacing is performed when immediate implantation of a pacemaker is not possible.

· Temporary cardiac pacing is performed in cases of hemodynamic instability, primarily due to Morgagni-Edams-Stokes attacks.

· Temporary cardiac pacing is carried out when there is reason to believe that bradycardia is transient (in case of myocardial infarction, the use of medications that can inhibit the formation or conduction of impulses, after cardiac surgery).

· Temporary cardiac pacing is recommended for the purpose of prevention in patients with acute myocardial infarction of the anteroseptal region of the left ventricle with blockade of the right and anterosuperior branches of the left bundle branch, due to the increased risk of developing complete atrioventricular block with asystole due to the unreliability of the ventricular pacemaker in this case.

Complications of temporary pacing

· Displacement of the electrode and impossibility (cessation) of electrical stimulation of the heart.

· Thrombophlebitis.

· Sepsis.

· Air embolism.

· Pneumothorax.

· Perforation of the heart wall.

Cardioversion-defibrillation

Cardioversion-defibrillation (electrical pulse therapy - EIT) - is a transsternal direct current of sufficient strength to cause depolarization of the entire myocardium, after which the sinoatrial node (first-order pacemaker) resumes control of the heart rhythm.

There are cardioversion and defibrillation:

1. Cardioversion - direct current exposure synchronized with the QRS complex. For various tachyarrhythmias (except ventricular fibrillation), the effect of direct current must be synchronized with the QRS complex, because If exposed to current before the peak of the T wave, ventricular fibrillation may occur.

2. Defibrillation. The impact of direct current without synchronization with the QRS complex is called defibrillation. Defibrillation is carried out in case of ventricular fibrillation, when there is no need (and no possibility) to synchronize the effects of direct current.

Indications for cardioversion-defibrillation

· Ventricular flutter and fibrillation. Electropulse therapy is the method of choice. More details: Cardiopulmonary resuscitation at a specialized stage in the treatment of ventricular fibrillation.

· Persistent ventricular tachycardia. In the presence of impaired hemodynamics (Morgagni-Adams-Stokes attack, arterial hypotension and/or acute heart failure), defibrillation is carried out immediately, and if it is stable, after an attempt to relieve it with medications if it is ineffective.

· Supraventricular tachycardia. Electropulse therapy is performed for health reasons with progressive deterioration of hemodynamics or routinely when drug therapy is ineffective.

· Atrial fibrillation and flutter. Electropulse therapy is performed for health reasons with progressive deterioration of hemodynamics or routinely when drug therapy is ineffective.

· Electropulse therapy is more effective for tachyarrhythmias of the reentry type, less effective for tachyarrhythmias as a result of increased automaticity.

· Electropulse therapy is absolutely indicated for shock or pulmonary edema caused by tachyarrhythmia.

· Emergency electropulse therapy is usually performed in cases of severe (more than 150 per minute) tachycardia, especially in patients with acute myocardial infarction, unstable hemodynamics, persistent anginal pain, or contraindications to the use of antiarrhythmic drugs.

All ambulance teams and all units must be equipped with a defibrillator medical institutions, and all health workers should be proficient in this method of resuscitation.

Methodology for cardioversion-defibrillation

In case of elective cardioversion, the patient should not eat for 6-8 hours to avoid possible aspiration.

Due to the painfulness of the procedure and the patient’s fear, general anesthesia or intravenous analgesia and sedation are used (for example, fentanyl at a dose of 1 mcg/kg, then midazolam 1-2 mg or diazepam 5-10 mg; for elderly or weakened patients - 10 mg promedol). For initial respiratory depression, non-narcotic analgesics are used.

When performing cardioversion-defibrillation, you must have the following kit on hand:

· Instrumentation for maintaining airway patency.

· Electrocardiograph.

· Ventilator.

· Medications and solutions necessary for the procedure.

· Oxygen.

Sequence of actions when performing electrical defibrillation:

· The patient should be in a position that allows, if necessary, tracheal intubation and closed cardiac massage.

· Reliable access to the patient's vein is required.

· Turn on the power supply, turn off the defibrillator timing switch.

· Set the required charge on the scale (approximately 3 J/kg for adults, 2 J/kg for children); charge the electrodes; Lubricate the plates with gel.

· It is more convenient to work with two hand electrodes. Place the electrodes on the anterior surface of the chest:

One electrode is installed above the zone of cardiac dullness (in women - outward from the apex of the heart, outside the mammary gland), the second - under the right collarbone, and if the electrode is spinal, then under the left scapula.

Electrodes can be placed in an anteroposterior position (along the left edge of the sternum in the area of ​​the 3rd and 4th intercostal spaces and in the left subscapular region).

Electrodes can be placed in an anterolateral position (in the space between the clavicle and the 2nd intercostal space along the right edge of the sternum and above the 5th and 6th intercostal space, in the area of ​​the apex of the heart).

· To minimize electrical resistance during electric pulse therapy, the skin under the electrodes is degreased with alcohol or ether. In this case, use gauze pads well moistened with isotonic sodium chloride solution or special pastes.

· The electrodes are pressed firmly and firmly against the chest wall.

· Perform cardioversion-defibrillation.

The discharge is applied at the moment of complete exhalation of the patient.

If the type of arrhythmia and the type of defibrillator allow it, the shock is delivered after synchronization with the QRS complex on the monitor.

Immediately before applying the shock, you should make sure that the tachyarrhythmia for which electropulse therapy is being performed persists!

For supraventricular tachycardia and atrial flutter, a shock of 50 J is sufficient for the first impact. For atrial fibrillation or ventricular tachycardia, a shock of 100 J is required for the first impact.

In the case of polymorphic ventricular tachycardia or ventricular fibrillation, a shock of 200 J is used for the first impact.

If the arrhythmia persists, with each subsequent discharge the energy is doubled up to a maximum of 360 J.

The time interval between attempts should be minimal and is required only to assess the effect of defibrillation and set, if necessary, the next shock.

If 3 shocks with increasing energy do not restore the heart rhythm, then the fourth - maximum energy - is applied after the intravenous administration of an antiarrhythmic drug indicated for this type of arrhythmia.

· Immediately after electropulse therapy, the rhythm should be assessed and, if it is restored, a 12-lead ECG should be recorded.

If ventricular fibrillation continues, antiarrhythmic drugs are used to reduce the defibrillation threshold.

Lidocaine - 1.5 mg/kg intravenously, as a bolus, repeat after 3-5 minutes. In case of restoration of blood circulation, a continuous infusion of lidocaine is performed at a rate of 2-4 mg/min.

Amiodarone - 300 mg intravenously over 2-3 minutes. If there is no effect, you can repeat the intravenous administration of another 150 mg. In case of restoration of blood circulation, a continuous infusion of 1 mg/min (360 mg) is carried out in the first 6 hours, and 0.5 mg/min (540 mg) in the next 18 hours.

Procainamide - 100 mg intravenously. If necessary, the dose can be repeated after 5 minutes (up to a total dose of 17 mg/kg).

Magnesium sulfate (Cormagnesin) - 1-2 g intravenously over 5 minutes. If necessary, the administration can be repeated after 5-10 minutes. (with tachycardia of the “pirouette” type).

After administering the medicine, general resuscitation measures are carried out for 30-60 seconds, and then electrical pulse therapy is repeated.

For intractable arrhythmias or sudden cardiac death, it is recommended to alternate the administration of drugs with electrical pulse therapy according to the following scheme:

· Antiarrhythmic drug - shock 360 J - adrenaline - discharge 360 ​​J - antiarrhythmic drug - shock 360 J - adrenaline, etc.

· You can apply not 1, but 3 discharges of maximum power.

· The number of digits is not limited.

If ineffective, general resuscitation measures are resumed:

Tracheal intubation is performed.

Provide venous access.

Adrenaline is administered 1 mg every 3-5 minutes.

Increasing doses of adrenaline 1-5 mg every 3-5 minutes or intermediate doses of 2-5 mg every 3-5 minutes can be administered.

Instead of adrenaline, vasopressin 40 mg can be administered intravenously once.

·Safety rules when working with a defibrillator

Eliminate the possibility of grounding personnel (do not touch the pipes!).

Avoid the possibility of others touching the patient while the shock is being administered.

Make sure that the insulating part of the electrodes and your hands are dry.

Complications of cardioversion-defibrillation

· Post-conversion arrhythmias, and above all – ventricular fibrillation.

Ventricular fibrillation usually develops when the shock is delivered in the vulnerable phase cardiac cycle. The probability of this is low (about 0.4%), however, if the patient’s condition, type of arrhythmia and technical capabilities allow, synchronization of the discharge with the R wave on the ECG should be used.

If ventricular fibrillation occurs, a second shock with an energy of 200 J is immediately applied.

Other post-conversion arrhythmias (eg, atrial and ventricular premature beats) are usually short-lived and do not require special treatment.

Pulmonary embolism and great circle blood circulation

Thromboembolism more often develops in patients with thromboendocarditis and with long-term atrial fibrillation in the absence of adequate preparation with anticoagulants.

· Breathing disorders.

Breathing disorders are a consequence of inadequate premedication and analgesia.

To prevent the development of breathing disorders, complete oxygen therapy should be carried out. Often, developing respiratory depression can be managed with verbal commands. You should not try to stimulate breathing with respiratory analeptics. For severe breathing problems, intubation is indicated.

· Skin burns.

Skin burns occur due to poor contact of electrodes with the skin and the use of repeated discharges with high energy.

· Arterial hypotension.

Arterial hypotension rarely develops after cardioversion-defibrillation. Hypotension is usually mild and does not last long.

· Pulmonary edema.

Pulmonary edema rarely occurs 1-3 hours after restoration of sinus rhythm, especially in patients with long-standing atrial fibrillation.

· Changes in repolarization on the ECG.

Changes in repolarization on the ECG after cardioversion-defibrillation are multidirectional, nonspecific and can persist for several hours.

· Changes in biochemical analysis blood.

Increases in enzyme activity (AST, LDH, CPK) are mainly associated with the effect of cardioversion-defibrillation on skeletal muscles. The activity of MV CPK increases only with repeated high-energy discharges.

Contraindications for EIT:

1. Frequent, short-term paroxysms of AF, self-limiting or with medication.

2. Permanent form of atrial fibrillation:

More than three years old

The date is unknown.

Cardiomegaly

Frederick's syndrome

Glycoside intoxication,

TELA up to three months,

LIST OF REFERENCES USED

1. A.G.Miroshnichenko, V.V.Ruksin St. Petersburg medical Academy postgraduate education, St. Petersburg, Russia “Protocols for the diagnostic and treatment process at the prehospital stage”

2. http://smed.ru/guides/67158/#Pokazaniya_k_provedeniju_kardiversiidefibrillyacii

3. http://smed.ru/guides/67466/#_Pokazaniya_k_provedeniju_jelektrokardiostimulyacii

4. http://cardiolog.org/cardiohirurgia/50-invasive/208-vremennaja-ecs.html

5. http://www.popumed.net/study-117-13.html